The prevalence of congenital heart disease (CHD) has surged in recent decades, owing to a substantial reduction in mortality. As individuals with CHD age, they become increasingly susceptible to late complications including arrhythmias. These arrhythmias often arise decades after surgical intervention and significantly impact quality of life, hospitalizations, and mortality. Catheter ablation has gained widespread acceptance as a critical intervention for managing arrhythmias in patients with CHD. However, anatomical and physiological features unique to this population pose challenges to standard manual ablation procedures, potentially impacting safety and efficacy. Robotic magnetic-guided navigation (RMN) has emerged as a technological solution to address these challenges. By utilizing soft and flexible catheters equipped with magnets at their tips, RMN enables robotic steering and orientation of catheters in three-dimensional space. This technology overcomes obstacles such as distorted vascular pathways and complex post-surgical reconstructions to facilitate access to target chambers and improve maneuverability within the heart. In this review, we present an overview of the safety and efficacy evidence for RMN-guided catheter ablation in CHD patients and highlight potential advantages. Additionally, we provide a detailed case presentation illustrating the practical application of RMN technology in this population. Although the literature on RMN-guided ablation in patients with CHD remains limited, it has shown promise in achieving successful outcomes, particularly in cases where manual ablation failed or was deemed non-feasible. Further validation through large-scale prospective studies is necessary to fully ascertain the benefits of RMN technology in this patient population.

The impact of Cardiac Implantable Electronic Devices’ (CIED) lead management on tricuspid valve disease (TVD) is an emergent topic. We report our single center experience on transvenous lead extraction (TLE) performed for tricuspid valve disease (TVD), the subsequent CIED management post-TLE and TVD therapy post-TLE.

Background:Although depression is a major issue among farming population, to date, there have been few studies on specific agricultural activities. We aimed to investigate whether, among the entire French farm manager (FM) workforce, certain agricultural activities are more strongly associated with depression than others. Methods:This nationwide retrospective cohort study used data from an administrative health database available to the TRACTOR project. This database pertains to the entire French agricultural workforce (overseas workers not included). Data were analyzed from January 2021 to December 2022. All FMs that worked at least once over the period 2002-2016 were included. The outcome measure was the association between 26 agricultural activities and the risk of depression measured as hazard ratios (HRs) after adjusting for age, sex, and pre-existing medical comorbidities. The time to first depression insurance declaration, or first antidepressant prescription claim was used as the underlying timescale. For each activity, the reference/control group included all FMs that never performed the considered activity between 2002 and 2016, while the exposed group included FMs that performed the considered activity at least once from 2002 to 2016. Four sensitivity analyses were conducted to test hypotheses, and to address potential sources of bias. Findings:There were 84,507 (7.76%; 28.2 cases per 1000 person-years) depression cases among 1,088,561 FMs (mean age 46.6 [SD 14.1]). Compared to other activities, dairy farming (HR = 1.37, 95% confidence interval: 1.32-1.42), cow farming (HR = 1.53 [1.47-1.59]), poultry and rabbit farming (HR = 1.37 [1.27-1.50]), and mixed farming (HR = 1.30 [1.24-1.36]) were more strongly associated with depression. Sex differences were observed, with most of the time, risks higher for females than for males. Interpretation:Agricultural activities at risk of depression among the entire French agricultural workforce were identified. These findings do represent a crucial first step on the road to implement effective preventive measures against depression to determine where additional resources should be allocated to screen for depression, along with intervention. Funding:MIAI@Grenoble Alpes, and Mutualité Sociale Agricole.

Patients with new-onset left bundle branch block (LBBB) after transcatheter aortic valve implantation (TAVI) are at risk of developing delayed high-degree atrioventricular block. Management of new-onset LBBB post-TAVI remains controversial. In the Comparison of a Clinical Monitoring Strategy Versus Electrophysiology-Guided Algorithmic Approach in Patients With a New LBBB After TAVI (COME-TAVI) trial, consenting patients with new-onset LBBB that persists on day 2 after TAVI, meeting exclusion/inclusion criteria, are randomized to an electrophysiological study (EPS)-guided approach or 30-day electrocardiographic monitoring. In the EPS-guided approach, patients with a His to ventricle (HV) interval ≥ 65 ms undergo permanent pacemaker implantation. Patients randomized to noninvasive monitoring receive a wearable continuous electrocardiographic recording and transmitting device for 30 days. Follow-up will be performed at 3, 6, and 12 months. The primary endpoint is a composite outcome designed to capture net clinical benefit. The endpoint incorporates major consequences of both strategies in patients with new-onset LBBB after TAVI, as follows: (i) sudden cardiac death; (ii) syncope; (iii) atrioventricular conduction disorder requiring a pacemaker (for a class I or IIa indication); and (iv) complications related to the pacemaker or EPS. The trial incorporates a Bayesian design with a noninformative prior, outcome-adaptive randomization (initially 1:1), and 2 prespecified interim analyses once 25% and 50% of the anticipated number of primary endpoints are reached. The trial is event-driven, with an anticipated upper limit of 452 patients required to reach 77 primary outcome events over 12 months of follow-up. In summary, the aim of this Bayesian multicentre randomized trial is to compare 2 management strategies in patients with new-onset LBBB post-TAVI—an EPS-guided approach vs noninvasive 30-day monitoring. Trial registration number: NCT03303612.

Polygenic risk scores (PRS) were recently shown to be associated with preexisting atrial fibrillation (AF) and to be predictive of incident AF. Previous studies using limited PRS to predict recurrent AF following pulmonary vein isolation (PVI) showed inconsistent results. We sought to evaluate the association of PRS with AF recurrence following ablation using a genome-wide PRS combining >6 million single nucleotide polymorphisms (PRSAF) and, in a secondary analysis, a PRS limited to a locus involved in pulmonary vein development comprising the PITX2 gene (PRSPITX2).

Background:The identification of low-voltage proarrhythmic areas for catheter ablation of scar-mediated ventricular tachycardia (VT) remains challenging. Integration of myocardial perfusion imaging (single-photon emission computed tomography/computed tomography; SPECT/CT) and electroanatomical mapping (EAM) may improve delineation of the arrhythmogenic substrate. Objective:To assess the feasibility of SPECT/CT image integration with voltage maps using the EnSite Precision system (Abbott) in patients undergoing scar-mediated VT ablation. Methods:Patients underwent SPECT/CT imaging prior to left ventricular (LV) EAM with the EnSite Precision mapping system. The SPECT/CT, EAM data, and ablation lesions were retrospectively co-registered in the EnSite Precision system and exported for analysis. Segmental tissue viability scores were calculated based on SPECT/CT perfusion and electrogram bipolar voltage amplitude. Concordance, specificity, and sensitivity between the 2 modalities as well as the impact of SPECT/CT spatial resolution were evaluated. Results:Twenty subjects (95% male, 67 ± 7 years old, left ventricular ejection fraction 36% ± 11%) underwent EAM and SPECT/CT integration. A concordance of 70% was found between EAM and SPECT/CT for identification of cardiac segments as scar vs viable, with EAM showing a 68.5% sensitivity and 76.4% specificity when using SPECT/CT as a gold standard. Projection on low-resolution 3D geometries led to an average decrease of 38% ± 22% of the voltage points used. Conclusion:The study demonstrated the feasibility of integrating SPECT/CT with EAM performed retrospectively for characterization of anatomical substrates during VT ablation procedures.

INTRODUCTION:Atrial fibrillation (AF) is a common chronic and progressive heart rhythm disorder. For those in whom sinus rhythm is desired, contemporary clinical practice guidelines recommend antiarrhythmic drugs (AADs) as the initial therapy. However, these medications have modest efficacy and are associated with significant adverse effects.AREAS COVERED:The current article reviews the evidence surrounding first-line catheter ablation, particularly the emerging evidence surrounding the use of cryoballoon ablation as a first-line therapy. The focus of the review is on the outcomes of arrhythmia freedom, quality of life, health-care utilization, and safety. In addition, the article will review novel cryoablation systems.EXPERT OPINION:Recent evidence suggests that cryoballoon ablation significantly improves arrhythmia outcomes (e.g. freedom from any atrial tachyarrhythmia or symptomatic atrial tachyarrhythmia, reduction in arrhythmia burden), patient-reported outcomes (e.g. symptoms and quality of life), and health-care resource utilization (e.g. hospitalization), without increasing the risk of adverse events. These findings are relevant to patients, providers, and health-care systems, as they help inform the decision-making regarding the initial choice of rhythm-control therapy in patients with treatment-naive AF.

Utilization of the subcutaneous implantable cardioverter-defibrillator (S-ICD) has increased over the past decade, as an extravascular alternative to the transvenous ICD. With this growing experience, we are facing new complications. This case report aims to outline a unique complication of an intrathoracic S-ICD lead positioning.

The 2020 HRS Expert Consensus statement recommends insertion of a temporary pacemaker for 24-48 hours in all patients developing left bundle branch block (LBBB) after transcatheter aortic valve implantation (TAVI). Despite its overall safety, temporary pacemaker insertion can result in rare but severe complications, especially in frail elderly patients.

BACKGROUND:Early recurrence of atrial tachyarrhythmia (ERAT) is common after pulmonary vein isolation (PVI) and has been associated with an increased risk of late atrial fibrillation (AF) recurrence.OBJECTIVE:The purpose of this study was to determine the incidence and outcomes of patients experiencing ERAT after PVI using advanced-generation ablation technologies.METHODS:This is a prespecified substudy of the CIRCA-DOSE (Cryoballoon vs Irrigated Radiofrequency Catheter Ablation: Double-Short vs Standard Exposure Duration) trial, a prospective, randomized, multicenter study comparing PVI with contact force-guided radiofrequency ablation to secondary-generation cryoballoon ablation for paroxysmal AF. All study patients received an implantable cardiac monitor to allow continuous rhythm monitoring. ERAT was defined as any recurrent atrial tachyarrhythmia within the first 90 days after AF ablation.RESULTS:ERAT occurred in 61% of the 346 patients at a median of 12 days (range 1-90 days) after ablation. ERAF was a significant predictor of late recurrence (60.1% with ER vs 25.9% without ER; P <.001) and symptomatic atrial tachyarrhythmia (31.6% with ERAF vs 6.7% without ERAF; P <.001). Receiver operating curve analyses revealed a strong correlation between ERAT timing and burden and late recurrence. Multivariate analysis identified ER timing (hazard ratio [HR] 2.90; 95% confidence interval [CI] 1.41-5.95; P = .004) and burden (HR 1.05 per 1% ER burden; 95% CI 1.04-1.07; P <.001) as strong independent predictors of late recurrence. Incidence rate, timing, burden, and prognostic significance of ER did not differ between the study groups.CONCLUSION:ERAT remains common after PVI despite use of advanced-generation ablation technologies. Early AF recurrence beyond 3 weeks after ablation is associated with increased risk of late recurrence.

BACKGROUND Use of intraprocedural observation and pharmacologic challenges have been proposed as means to differentiate permanent pulmonary vein (PV)-left atrial conduction block from inadequate ablation lesions. OBJECTIVE The purpose of this study was to determine the prevalence and clinical impact of spontaneous and adenosine-provoked reconnection using contemporary atrial fibrillation (AF) ablation technologies. METHODS The CIRCA-DOSE (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration) study enrolled 346 patients with paroxysmal AF and randomized them to contact force-guided radiofrequency ablation (CF-RF) or cryoballoon ablation. Patients underwent provocative testing with adenosine after a 20-minute observation period. All patients received an implantable cardiac monitor for arrhythmia monitoring. RESULTS Spontaneous reconnection was observed in 5.4% of PVs (71/1318) during the 20-minute postprocedure observation period, and dormant conduction was elicited in 5.7% of PVs (75/1318). Both spontaneous reconnection and dormant conduction were more common after CF-RF compared to cryoballoon ablation (P = .03 and P<.0001, respectively). Acute PV reconnection (spontaneous or adenosine-provoked) was associated with a significantly higher incidence of recurrent atrial tachyarrhythmia in the cryoballoon group (hazard ratio [HR] 2.39; 95% confidence interval [CI] 1.44-3.96; P = .0007) but not in the CF-RF group (HR 1.47; 95% CI 0.84-2.58; P = .16). In the absence of acute reconnection, the freedom from recurrent arrhythmia did not differ between groups (HR 0.95; 95% CI 0.6057-1.495; P=.83). CONCLUSION Patients without spontaneous or adenosine-provoked reconnection had better outcomes compared to those with acute PV reconnection, suggesting that efforts should be directed toward ensuring an ideal ablation lesion at the first attempt in order to achieve durable PV isolation.

Left ventricle (LV) substrate can be characterized by imaging modalities providing physiological variables (tissue perfusion, ischemia, etc.) grouped in a complex dataset. Principal Component Analysis (PCA) can identify the dataset variables that best explain its variance. Variables linked to substrate arrhythmogenicity will lead PCA to identify LV regions most influenced by the variables on a LV 3D geometry. To evaluate whether regions identified by PCA correspond to regions targeted by physicians in a ventricular tachycardia (VT) ablation procedure. Ischemic VT subjects underwent SPECT/CT perfusion imaging (rest and stress) prior to LV voltage mapping with the cardiac mapping system. Co-registration allowed projection of ablation sites onto SPECT/CT geometries. PCA retrospectively analyzed the following dataset: tissue perfusion (rest and stress), tissue ischemia and the local (1cm2 sub-regions) stress-rest difference for: 1) standard deviation (STD) and 2) skewness (Skew). PCA components (PCAc) explaining ≥85% of the total variance were plotted on the LV 3D geometry to display regions highly influenced by the dataset variables (see figure below). Ten subjects (9 males, 66 ± 8 years old, LVEF 37 ± 11%) underwent co-registration. In 7/10 subjects, tissue perfusion (in PCAc#1) and ischemia (in PCAc#2) were most influential on LV regions variance. Ischemia and low perfusion (≤40%) areas equaled 32 ± 19 % of the LV with 21 ± 23% of these areas highly involved in the arrhythmogenic substrate (≥75% of explained LV variance). The location of 63 ± 18% of ablation sites were <1 cm from areas explaining ≥50% of LV variance. Preliminary results showed that PCA can synthesize the influence of different perfusion derived variables, like tissue perfusion and ischemia, used in SPECT/CT imaging of the LV. Further analysis is needed to confirm whether this could be used to select VT ablation targets. Abstract Figure.

OBJECTIVES This study evaluated the impact of contact force-guided radiofrequency ablation versus cryoballoon ablation on quality of life and health care utilization. BACKGROUND Traditional outcome parameters, such as arrhythmia-free survival, are insufficient to evaluate the clinical impact of atrial fibrillation (AF), as it fails to the capture patient- and health system-level differences in treatment approaches. METHODS The CIRCA-DOSE (Cryoballoon Vs. Contact-Force Atrial Fibrillation Ablation) study randomly assigned 346 patients with drug-refractory paroxysmal AF to contact force-guided radiofrequency or cryoballoon ablation. Health-related quality-of-life (HRQOL) was assessed at baseline, and at 6 and 12 months post-ablation using a disease-specific and generic HRQOL instruments. Health care utilization (hospitalization, emergency department visits, and cardioversion) and antiarrhythmic drug use for the 12 months preceding ablation was compared with the 12 months following ablation. RESULTS Disease-specific and generic HRQOL was moderately to severely impaired at baseline and improved significantly at 6 and 12 months of follow-up (median improvement in AFEQT [Atrial Fibrillation Effect on QualiTy of Life] score 32.4 [interquartile range: 17.7 to 48.9]). When compared with the 12 months pre-ablation, the proportion and absolute number of cardioversions decreased significantly (41.1% vs. 10.1% of patients, 137 vs. 35 events; p < 0.0001). Similar significant reductions in emergency department visits (66.7% vs. 25.1% of patients, 224 vs. 87 events; p < 0.0001), and hospitalizations (25.5% vs. 14.5% of patients, 86 vs. 50 events; p < 0.001) were observed. There were no significant differences between randomized groups. CONCLUSIONS In this multicenter randomized trial, catheter ablation with advanced-generation technologies resulted in a significant improvement in HRQOL and a significant reduction in health care utilization in the year following AF ablation. (C) 2020 by the American College of Cardiology Foundation.

BACKGROUND:Pulmonary vein (PV) stenosis is a complication of atrial fibrillation (AF) ablation. The incidence of PV stenosis after routine post-ablation imaging remains unclear and is limited to single-centre studies. Our objective was to determine the incidence and predictors of PV stenosis following circumferential radiofrequency ablation in the multicentre Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination (ADVICE) trial. METHODS:Patients with symptomatic AF underwent circumferential radiofrequency ablation in one of 13 trial centres. Computed tomographic (CTA) or magnetic resonance (MRA) angiography was performed before ablation and 90 days after ablation. Two blinded reviewers measured PV diameters and areas. PVs with stenosis were classified as severe (> 70%), moderate (50%-70%), or mild (< 50%). Predictors of PV stenosis were identified by means of multivariable logistic regression. RESULTS:A total of 197 patients (median age 59.5 years, 29.4% women) were included in this substudy. PV stenosis was identified in 41 patients (20.8%) and 47 (8.2%) of 573 ablated PVs. PV stenosis was classified as mild in 42 PVs (7.3%) and moderate in 5 PVs (0.9%). No PVs had severe stenosis. Both cross-sectional area and diameter yielded similar classifications for severity of PV stenosis. Diabetes was associated with a statistically significant increased risk of PV stenosis (OR 4.91, 95% CI 1.45-16.66). CONCLUSIONS:In the first systematic multicentre evaluation of post-ablation PV stenosis, no patient acquired severe PV stenosis. Although the results are encouraging for the safety of AF ablation, 20.8% of patients had mild or moderate PV stenosis, in which the long-term effects are unknown.

BACKGROUND:Access to pacemakers and defibrillators is problematic in places with limited resources. Resterilization and reuse of implantable cardiac devices obtained post mortem from patients in wealthier nations have been undertaken, but uncertainty around the risk of infection is a concern. METHODS:A multinational program was initiated in 1983 to provide tested and resterilized pacemakers and defibrillators to underserved nations; a prospective registry was established in 2003. Patients who received reused devices in this program were matched in a 1:3 ratio with control patients who received new devices implanted in Canada. The primary outcome was infection or device-related death, with mortality from other causes modeled as a competing risk. RESULTS:Resterilized devices were implanted in 1051 patients (mean [±SD] age, 63.2±18.5 years; 43.6% women) in Mexico (36.0%), the Dominican Republic (28.1%), Guatemala (26.6%), and Honduras (9.3%). Overall, 85% received pacemakers and 15% received defibrillators, with one (55.5%), two (38.8%), or three (5.7%) leads. Baseline characteristics did not differ between these patients and the 3153 matched control patients. At 2 years of follow-up, infections had occurred in 21 patients (2.0%) with reused devices and in 38 (1.2%) with new devices (hazard ratio, 1.66; 95% confidence interval, 0.97 to 2.83; P = 0.06); there were no device-related deaths. The most common implicated pathogens were Staphylococcus aureus and S. epidermidis. CONCLUSIONS:Among patients in underserved countries who received a resterilized and reused pacemaker or defibrillator, the incidence of infection or device-related death at 2 years was 2.0%, an incidence that did not differ significantly from that seen among matched control patients with new devices in Canada.