BackgroundThe value of cardiac magnetic resonance (CMR) imaging in cases of premature ventricular contractions (PVCs) has not been clearly defined.ObjectivesTo assess the ability of CMR to detect structural abnormalities in patients referred for PVCs and to determine predictive factors.Methods200 consecutive patients were retrospectively included after a workup that included an electrocardiogram, echocardiography, and an exercise test. We determined whether or not CMR could reveal previously undetected structural abnormalities.ResultsCMR revealed structural abnormalities in 92 patients (46% of cases): nonischemic fibrosis (n = 53, 26.5%), ischemic fibrosis (n = 18, 9%), mixed fibrosis (n = 4, 2%), and 4 (2%) cardiomyopathies. In a multivariate analysis, the main predictors of structural abnormalities were age [odds ratio (OR): 1.03; p = 0.016], male sex (OR: 2.48; p = 0.019), diabetes (OR: 5.02; p = 0.010), smoking (OR: 2.09; p = 0.047), known cardiomyopathy (OR: 3.24; p = 0.006), pleomorphic PVCs (OR: 2.48; p = 0.051), and the absence of a decrease in PVC frequency during exercise (OR: 0.24; p < 0.001). In contrast, all young, nondiabetic subjects with unknown cardiomyopathy, normal echocardiography, and monomorphic PVC that decreased in frequency with effort had normal CMR findings.ConclusionsCMR is essential in the investigation of PVCs; it enabled the detection of structural abnormalities not found during the initial workup in 46% of the cases. Predictive factors included male sex, age, diabetes, smoking, known cardiomyopathy, and pleomorphic PVCs. In contrast, young and nondiabetic patients with normal echocardiography and monomorphic PVCs that decrease in frequency with effort had normal CMR findings; raising the hypothesis that the usefulness of CMR in this specific population should be discussed.

Substrate ablation strategies in addition to pulmonary vein isolation (PVI) for the maintenance of sinus rhythm (SR) are still debated. Targeting low voltage areas (LVA) in addition to PVI may represent an efficient strategy for the ablation of persistent atrial fibrillation (AF). SCAR-AF study (ablation of LVA during sinus rhythm) was a multicenter, prospective, randomized trial, evaluating the effect of LVA ablation in addition to PVI for persistent AF on SR maintenance. From September 2019 to August 2021, patients with de novo persistent AF were included in the study. After LA mapping guided by a 3D mapping system, patients were divided according to the presence or absence of LVA. Patients without LVA were treated by PVI only (Group A). Patients with LVA were randomized to PVI only (Group B) or PVI + ablation of LVA (Group C). LVA was defined as voltage mapping with bipolar atrial voltage <0.5 mV. The primary endpoint was freedom from atrial arrhythmias, after a single ablation procedure. A total of 211 patients (Sex male: 73%, Mean Age 63.8+/-9.3 years, CHADS-VASC 2.1, long standing AF 33.5%). After 18 months FU, atrial-arrhythmia-free survival did not differ significantly between the 3 groups, 79% in Group A, 75.7% in Group B, 73.1% in Group C (Group A vs Group B: HR: 1.28; 95% CI: 0.64-2.55, p = .48, Group B vs Group C: HR 95%CI: 0.67-2.45; p = 0.45). Multivariate analysis showed that presence of LVA was associated with age (years) (HR 1.11 CI 1.06 – 1.16, p < 0.001) and inversely correlated with BMI (kg/m²) (HR 0.93, CI 0.87 – 0.99, p 0.029) and current smoking. In this randomized trial, PVI plus ablation of LVA did not significantly improved outcomes in patients with persistent AF. LVA may represent a marker of severe atrial cardiomyopathy.

BACKGROUND:Targeting low-voltage areas (LVAs) in addition to pulmonary vein isolation (PVI) can improve ablation outcome in persistent atrial fibrillation (AF). OBJECTIVE:SCAR-AF was a multicenter, prospective, randomized trial, evaluating LVA ablation plus PVI for persistent AF. METHODS:Patients with de novo persistent AF were recruited (9 referral centers in France) into the SCAR-AF study (September 2019 to August 2021). Patients without LVA were treated with PVI alone (PVI-), and those with LVA were randomized to either PVI alone (PVI+) or PVI plus LVA ablation (PVI + LVA). The primary outcome was freedom from atrial arrhythmias (AF/atrial tachycardia) after a single procedure. RESULTS:A total of 211 patients (73.5% men, mean ± standard deviation age 63.8 ± 9.3 years, CHA2DS2-VASc score 2.1, long-standing AF 44.5%) were included. At 18-month follow-up, the incidence of atrial-arrhythmia-free survival did not differ between groups (79.0% in PVI-, 75.7% in PVI+, and 73.1% in PVI + LVA; PVI- vs PVI+, hazard ratio (HR) 1.28, 95% confidence interval [CI] 0.64-2.55, P = .48; PVI+ vs PVI + LVA, HR 1.28; 95% CI 0.67-2.45, P = .45). On multivariable analysis, presence of LVA was associated with advancing age (HR 1.11, 95% CI 1.06-1.16, P < .001) and was inversely correlated with body mass index (HR 0.93, 95% CI 0.87-0.99, P = .029) and smoking. CONCLUSION:In this randomized trial, PVI plus LVA ablation did not improve outcomes in patients with persistent AF. LVA may represent a marker of atrial cardiomyopathy, but its presence does not seem to be an effective target in persistent AF.

Background: Percutaneous left atrial appendage closure may be considered in selected patients with atrial fibrillation at significant risk of both thromboembolism and haemorrhage. Aims: To report the experience of a tertiary French centre in percutaneous left atrial appendage closure and to discuss the outcomes compared with previously published series. Methods: This was a retrospective observational cohort study of all patients referred for percutaneous left atrial appendage closure between 2014 and 2020. Patient characteristics, procedural management and outcomes were reported, and the incidence of thromboembolic and bleeding events during follow-up were compared with historical incidence rates. Results: Overall, 207 patients had left atrial appendage closure (mean age 75.3 +/- 8.6 years; 68% men; CHA2DS2-VASc score 4.8 +/- 1.5 ; HAS-BLED score 3.3 +/- 1.1), with a 97.6% (n = 202) success rate. Twenty (9.7%) patients had at least one significant periprocedural complication, including six (2.9%) tamponades and three (1.4%) thromboembolisms. Periprocedural complication rates decreased from earlier to more recent periods (from 13% before 2018 to 5.9% after; P = 0.07). During a mean follow-up of 23.1 +/- 20.2 months, 11 thromboembolic events were observed (2.8% per patient-year), a 72% risk reduction compared with the estimated theoretical annual risk. Conversely, 21 (10%) patients experienced bleeding during follow-up, with almost half of the events occurring during the first 3 months. After the first 3 months, the risk of major bleeding was 4.0% per patient-year, a 31% risk reduction compared with the expected estimated risk. Conclusion: This real-world evaluation emphasizes the feasibility and benefit of left atrial appendage closure, but also illustrates the need for multidisciplinary expertise to initiate and develop this activity. (c) 2023 Published by Elsevier Masson SAS.

Aim. - We aimed to describe temporal trends in volume and outcomes of catheter ablation in patients with ACHD. Methods. - This was a retrospective observational study including all consecutive patients with ACHD undergoing attempted catheter ablation in a large tertiary referral centre over a 15-year period. Acute procedural success rate and freedom from recurrence at 12 and 24 months were analysed. Results. - From November 2004 to November 2019, 302 catheter ablations were performed in 221 patients with ACHD (mean age 43.6 +/- 15.0 years; 58.9% male sex). The annual number of catheter ablations increased progressively from four to 60 cases per year (P < 0.001). Intra-atrial reentrant tachycardia/focal atrial tachycardia was the most common arrhythmia (n = 217, 71.9%). Over the study period, acute procedural success rate increased from 45.0% to 93.4% (P < 0.001). Use of irrigated catheters (odds ratio [OR] 4.03, 95% confidence interval [CI] 1.86-8.55), a three-dimensional mapping system (OR 3.70, 95% CI 1.72-7.74), contact force catheters (OR 3.60, 95% CI 1.81-7.38) and high-density mapping (OR 3.69, 95% CI 1.82-8.14) were associated with acute procedural success. The rate of freedom from any recurrence at 12 months increased from 29.4% to 66.2% (P = 0.001). Seven (2.3%) non-fatal complications occurred. Conclusions. - The number of catheter ablation procedures in patients with ACHD has increased considerably over the past 15 years. Growing experience and advances in ablative technologies appear to be associated with a significant improvement in acute and mid-term outcomes. (c) 2021 Elsevier Masson SAS. All rights reserved.

RF ablation is a standard practice approach for the symptomatic AF. The interest of substrate ablation, completing pulmonary vein isolation is controversial. The current ablation strategy for persistent AF ablation is a step-by step guided approach: PVI is most often followed by a large ablation of fragmented electrograms identified in AF or completed by linear ablation, but this current ablation strategies have shown a limited success rate with frequent arrhythmia recurrences. Recent studies suggest that the atrial arrhythmogenic sites are related to regions with heterogeneities and increased fibrosis, which is detected by reduced bipolar voltage areas. Defragmentation low voltage areas (LVA) in sinus rhythm (SR) in addition to PVI may represent an efficient strategy for the ablation of persistent AF. This is a prospective multicentric interventional study in France. Inclusion criteria: minimum age 18 years, patients with persistent AF ablation, no specific indication restrictions or equipment used regardless of the outcome of the procedure. Number of patients: 210 patients included in 9 centres. Three groups will be constituted: Group 1: PVI without LVA identified, group 2: PVI only, with LVA identified but defragmentation will not be carried out and group 3: PVI with LVA identified and defragmentation will be carried out. Definition of LVA in SR: all potentials < 1 mV, fragmented signal: more than 5 deflexions, duration > 55 ms. Inducibility of AF is realised at the end of the procedure. Usual blanking period of 3 months. Follow-up: clinical evaluation, ECG, and 24h-holter ECG at 6, 12 and 18 months. Primary outcome: recurrence of AF at 18 months. Secondary outcomes: comparison of efficiency and safety of the procedures, procedural data (X-ray data, RF duration, AF inducibility), organised atrial tachycaria occurring during FU.

BACKGROUND While outcomes of intra-atrial reentrant/focal atrial tachycardia (IART/FAT) catheter ablation have considerably improved in adult congenital heart disease (ACHD), recurrences remain common with different circuits frequently encountered. OBJECTIVE We aimed to assess the value of programmed atrial stimulation after successful clinical IART/FAT catheter ablation in patients with ACHD. METHODS This is a retrospective study including all patients with ACHD undergoing IART/FAT catheter ablation in a tertiary center. After successful catheter ablation of clinical arrhythmia, survival free from arrhythmia recurrence was analyzed according to whether all inducible IARTs/FATs were targeted. RESULTS From 2004 to 2020, 238 IART/FAT catheter ablation procedures were performed (mean age 44.1 +/- 15.0 years; 61.3% men). Acute procedural success of clinical arrhythmia was achieved in 208 procedures (87.4%). Among 122 procedures with programmed atrial stimulation (58.7%), at least 1 other IART/FAT was induced in 61 patients (50 0 /o). All inducible IARTs/FATs were ablated in 54 pa- tients (88.5%), whereas 7 patients (11.5%) presented with at least 1 nontargeted inducible IART/FAT. Patients with nontargeted inducible IART/FAT had a higher risk of atrial arrhythmia episodes than did inducible patients treated with ablation of all IARTs/FATs (hazard ratio 5.7; 95% confidence interval 1.7-18.4; P = .004), with 12-month atrial arrhythmias recurrence rates of 22.9% and 77.7%, respectively. Inducible patients with successful ablation of all IARTs/FATs had a risk of recurrence similar to that of noninducible patients (hazard ratio 0.6; 95% confidence interval 0.3-1.3; P = .215). CONCLUSION Beyond clinical IART/FAT catheter ablation in patients with ACHD, our findings suggest the interest of systematically targeting all remaining inducible arrhythmias, irrespective of whether previously documented.

BACKGROUND:The experience with the implantable cardiac defibrillator (ICD) in patients with transposition of the great arteries (TGA) and history of atrial switch surgery remains limited.METHODS:Retrospective evaluation aiming to assess characteristics and outcomes of consecutive TGA patients with history of atrial switch surgery implanted with an ICD between January 2005 and June 2012 in four French centers.RESULTS:Of the 12 patients (median 34 years [28, 40]; 67% male), 4 patients (33%) were implanted for secondary prevention after symptomatic documented sustained ventricular tachycardia or sudden cardiac arrest. ICDs were implanted for primary prevention in 8 patients (67%), including cardiac resynchronization in 3 patients; severe systemic ventricle dysfunction was present in all cases (median ejection fraction 27% [20, 40]). Overall, one patient died during the ICD implantation secondary to refractory cardiac arrest after defibrillation testing. Over a median follow-up of 19 months [10, 106], 6 patients out of 11 (54%) experienced worsening of congestive heart failure, including 5 who were eventually transplanted. Overall, 3 patients (27%) experienced significant ICD-related complications, whereas only one patient (primary prevention indication) developed appropriate ICD therapy (successful anti-tachycardia pacing without shock). Half of the patients presented with at least one episode of sustained (≥ 5 min) atrial arrhythmia during follow-up.CONCLUSIONS:Our findings underline the key role of progressive heart failure in dictating outcomes among TGA patients with prior atrial switch repair. Our results also underline the need of better risk-stratification for sudden cardiac death in those patients.

The origin of 40% of syncope remains unknown even after a complete diagnostic work-up. Previous studies have suggested that adenosine 5’-triphosphate (ATP) testing has value in selecting successful therapy. This patient-blinded, multicenter, randomized superiority trial tested whether, in patients with syncope of unknown origin (SUO), selecting cardiac pacing in those with a positive ATP test results in fewer recurrences than those who do not receive pacing. From 2000 to 2005, 80 consenting patients (mean age 75.9±7.7 years; 81% women; 56% without diagnosed structural heart disease) with syncope of unknown origin and atrioventricular or sinoatrial block lasting longer than 10 seconds (average 17.9±6.8 seconds) under ATP administration (20 mg IV bolus) were recruited from 10 hospitals, implanted with programmable pacemakers and randomized to either active pacing (dual-chamber pacing at 70 beats per minute (bpm) or backup pacing (atrial pacing at 30 bpm). Patients were followed regularly for up to five years for any syncope recurrence, the primary outcome. Mean follow-up was 16 months. Syncope recurred in eight (21%) of 39 patients randomized to active pacing and in 27 (66%) of 41 randomized to backup pacing (control), yielding a hazard ratio of 0.25 (95% CI: 0.12–0.56). After recurrence, the 27 recurrent control patients were reprogrammed to active pacing and only one reported subsequent syncope. This study suggests that, in elderly patients with syncope of unknown origin and positive ATP tests, active dual-chamber pacing reduces syncope recurrence risk by 75% (95% confidence interval, 44–88).

Permanent pacemaker (PM) implantation is temporarily contraindicated in patients (pts) with sepsis. In patients with symptomatic atrioventricular (AV) block and infection, prolonged VVI pacing is therefore usually ensured by a ventricular pacing lead (PL) connected to an external PM generator. In patients with normal sinus function and heart failure, the VVI mode can exacerbate haemodynamic dysfunction. A single AV PL can be attractive to achieve physiological pacing. This study was designed to assess the efficacy and safety of temporary VDD pacing as a bridge to permanent PM implantation in patients with complete AV block until control of infection.This study included eight patients with complete AV block and sepsis with negative blood culture. Due to the presence of congestive heart failure, a single bipolar AV PL connected to an external VDD PM generator. At VDD implantation, P-wave amplitude was 1.9 1.6 mV and R-wave was 11.3 5.2 mV. The ventricular pacing threshold was 0.53 0.1 V for a 0.5 ms pulse. Antibiotic therapy was instituted in all patients. A permanent VDD or DDD PM was implanted after 8 2.5 days of temporary VDD pacing. At permanent PM implantation, the mean brain natriuretic peptide level had decreased and sepsis was controlled in all patients. No recurrence of sepsis was observed with a mean follow-up of 15.8 5.3 months.Temporary VDD pacing is a safe and effective method to achieve prolonged AV physiological pacing in patients with AV block until infection has been controlled.

Background— The origin of 40% of syncope cases remains unknown even after a complete diagnostic workup. Previous studies have suggested that ATP testing has value in selecting successful therapy. This patient-blinded, multicenter, randomized superiority trial tested whether, in patients with syncope of unknown origin, selecting cardiac pacing in those with a positive ATP test leads to fewer recurrences than those who do not receive pacing. Methods and Results— From 2000 to 2005, 80 consenting patients (mean age, 75.9±7.7 years; 81% women; 56% without diagnosed structural heart disease) with syncope of unknown origin and atrioventricular or sinoatrial block lasting >10 seconds (average, 17.9±6.8 seconds) under ATP administration (20-mg IV bolus) were recruited from 10 hospitals, implanted with programmable pacemakers, and randomized to either active pacing (dual-chamber pacing at 70 bpm) or backup pacing (atrial pacing at 30 bpm). Patients were followed up regularly for up to 5 years for any syncope recurrence, the primary outcome. Mean follow-up was 16 months. Syncope recurred in 8 of 39 patients (21%) randomized to active pacing and in 27 of 41 (66%) randomized to backup pacing (control), yielding a hazard ratio of 0.25 (95% confidence interval, 0.12–0.56). After recurrence, the 27 recurrent control patients were reprogrammed to active pacing, and only 1 reported subsequent syncope. Conclusion— This study suggests that, in elderly patients with syncope of unknown origin and positive ATP tests, active dual-chamber pacing reduces syncope recurrence risk by 75% (95% confidence interval, 44–88). Clinical Trial Registration— URL: http://www.controlled-trials.com/ISRCTN00029383 . Unique identifier: ISRCTN00029383.

The strategy of sudden cardiac death prevention by implantable cardioverter defibrillator, in primary prevention, is mainly based on the value of ejection fraction. That means that the approach is not really patient specific. A lot of implanted patients will not receive any shock. The implantation of large categories of patients is interesting on a global therapeutical point of view but, when considering the economical aspects, it would be more useful to have better selection criteria in order to obtain a more patient-specific approach, avoiding implanting patients who will never receive shocks. The parameters commonly used to select patients for implantations have a good negative predictive value but a low positive predictive value. Concerning atrial fibrillation the approach is quite different. Antiarrhythmic drug treatment has shown many limitations. Antiarrhythmic drugs are useful and safe in atrial fibrillation patients only if the contra-indications are strictly respected. The main difficulty concerns patients with both heart failure and atrial fibrillation. The story of Dronedarone development is illustrative of the necessity of a patient-specific approach in the treatment strategy of atrial fibrillation. The ATHENA trial made with Dronedarone showed a benefit in patients with underlying heart disease but no patient with advanced cardiopathy was included in the study. On the contrary, the PALLAS trial has clearly shown that the drug is contra-indicated in patients with any type of heart failure. In atrial fibrillation, a patient-specific approach is mandatory. This review illustrates the dichotomy of the two different approaches.

Background-The origin of 40% of syncope cases remains unknown even after a complete diagnostic workup. Previous studies have suggested that ATP testing has value in selecting successful therapy. This patient-blinded, multicenter, randomized superiority trial tested whether, in patients with syncope of unknown origin, selecting cardiac pacing in those with a positive ATP test leads to fewer recurrences than those who do not receive pacing.Methods and Results-From 2000 to 2005, 80 consenting patients (mean age, 75.9 +/- 7.7 years; 81% women; 56% without diagnosed structural heart disease) with syncope of unknown origin and atrioventricular or sinoatrial block lasting >10 seconds (average, 17.9 +/- 6.8 seconds) under ATP administration (20-mg IV bolus) were recruited from 10 hospitals, implanted with programmable pacemakers, and randomized to either active pacing (dual-chamber pacing at 70 bpm) or backup pacing (atrial pacing at 30 bpm). Patients were followed up regularly for up to 5 years for any syncope recurrence, the primary outcome. Mean follow-up was 16 months. Syncope recurred in 8 of 39 patients (21%) randomized to active pacing and in 27 of 41 (66%) randomized to backup pacing (control), yielding a hazard ratio of 0.25 (95% confidence interval, 0.12-0.56). After recurrence, the 27 recurrent control patients were reprogrammed to active pacing, and only 1 reported subsequent syncope.Conclusion-This study suggests that, in elderly patients with syncope of unknown origin and positive ATP tests, active dual-chamber pacing reduces syncope recurrence risk by 75% (95% confidence interval, 44-88).

Methods We retrospectively evaluated the CMR scans of 294 patients referred for ARVC between 2005 and 2010 and determined the presence or absence of major and minor CMR criteria using the original and the revised TFC. Previously, major and minor abnormalities were identified by the presence of RV dilatation (global or segmental), RV micro-aneurysm, or regional hypokinesis. The revised criteria require the combination of severe regional wall motion abnormalities (akinesis or dyskinesis or dyssynchrony) with global RV dilatation or dysfunction (quantitative assessment). For defining RV dilatation, we used the same quantitative cut-off values for both, original and revised criteria.

OBJECTIVES:The purpose of our study was to assess the impact of revised versus original criteria on the prevalence of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) criteria in cardiac magnetic resonance (CMR) studies. BACKGROUND:Recently, the ARVC/D task force criteria have been revised, aiming for a better diagnostic sensitivity. The implications of this revision on clinical decision making are unknown. METHODS:We retrospectively evaluated the CMR scans of 294 patients referred for ARVC/D between 2005 and 2010, and determined the presence or absence of major and minor CMR criteria using the original and the revised task force criteria. Previously, major and minor abnormalities were identified by the presence of right ventricle dilation (global or segmental), right ventricle microaneurysm, or regional hypokinesis. The revised criteria require the combination of severe regional wall motion abnormalities (akinesis or dyskinesis or dyssynchrony) with global right ventricle dilation or dysfunction (quantitative assessment). RESULTS:Applying the original criteria, 69 patients (23.5%) had major original criteria, versus 19 patients (6.5%) with the revised criteria. Forty-three patients (62.3%) with major original criteria did not meet any of the revised criteria. Using the original criteria, 172 patients (58.5%) had at least 1 minor criterion versus 12 patients (4%) with the revised task force criteria; 167 patients (97%) with minor original criteria did not meet any of the revised criteria. In the subgroup of 134 patients with complete diagnostic work-up of ARVC, 10 patients met the diagnosis of proven ARVC/D without counting imaging criteria. Only 4 of 10 met major criteria according to the revised CMR criteria; none met minor criteria. However, 112 of 124 patients without ARVC/D were correctly classified as negative by major and minor criteria (specificity 94% and 96%, respectively). CONCLUSIONS:In our experience, the revision of the ARVC/D task force imaging criteria significantly reduced the overall prevalence of major and minor criteria. The revision, although maintaining a high specificity, may not have improved the sensitivity for identifying patients with ARVC/D. Larger studies including follow-up are required.

Background Sudden cardiac death (SCD) is the predominant cause of mortality in patients with mild heart failure (HF). This 2-year follow-up, multicenter, cohort study aimed to assess the extent to which implantable cardioverter defibrillators (ICDs), by reducing SCD, lead to predominant progressive HF death in mildly symptomatic HF patients at baseline in daily medical practice.Methods Between June 2001 and June 2003, 1,030 New York Heart Association II patients received an ICD in 22 French centers. Sudden cardiac death and progressive HF mortality rates were assessed using competing risk methodology, and predictors for progressive HF at baseline were tested in a multivariate regression model.Results During a mean follow-up of 22 +/- 6 months, 114 deaths occurred: 12 (10.5%) due to SCD and 52 (45.6%) due to progressive HF (24-month cause-specific mortality rates of 1.2% [95% CI 0.6-1.9] and 5.4% [95% CI 4.0-6.8], respectively). Diuretics use (hazard ratio [HR] 2.8, 95% CI 1.5-5.5, P=.002), history of atrial fibrillation (HR 2.09, 95% CI 1.2-3.65, P=.01), and low ejection fraction (HR 2.7, 95% CI 1.4-4.8, P=.0008) were independent predictors for progressive HF death, whereas beta-blocker therapy was a protector (HR 0.6, 95% CI 0.3-0.9, P=.04). Half of the patients (48%) who died from progressive HF within 2 years of ICD implant initially presented with enlarged QRS (>= 120 milliseconds).Conclusions Because of ICD efficiency, progressive HF is the main cause of death within 2 years of implant, although these patients are only mildly symptomatic at implantation. In addition to optimal pharmacologic therapy, these results raise the question of systematically implanting ICDs with cardiac resynchronization therapy in patients with electrical asynchronism at baseline. (Am Heart J 2010; 159: 659-664. e1.)