Background: Recurrences of atrial fibrillation (AF) after pulmonary vein isolation (PVI) are mainly due to pulmonary vein reconnection. However, a growing number of patients have AF recurrences despite durable PVI. The optimal ablative strategy for these patients is unknown. We analyzed the impact of current ablation strategies in a large multicenter study. Methods: Patients undergoing a redo ablation for AF and presenting durable PVI were included. The freedom from atrial arrhythmia after pulmonary vein-based, linear-based, electrogram-based, and trigger-based ablation strategies were compared. Results: Between 2010 and 2020, 367 patients (67% men, 63±10 years, 44% paroxysmal) underwent a redo ablation for AF recurrences despite durable PVI at 39 centers. After durable PVI was confirmed, linear-based ablation was performed in 219 (60%) patients, electrogram-based ablation in 168 (45%) patients, trigger-based ablation in 101 (27%) patients, and pulmonary vein-based ablation in 56 (15%) patients. Seven patients (2%) did not undergo any additional ablation during the redo procedure. After 22±19 months of follow-up, 122 (33%) and 159 (43%) patients had a recurrence of atrial arrhythmia at 12 and 24 months, respectively. No significant difference in arrhythmia-free survival was observed between the different ablation strategies. Left atrial dilatation was the only independent factor associated with arrhythmia-free survival (HR, 1.59 [95% CI, 1.13–2.23]; P =0.006). Conclusions: In patients with recurrent AF despite durable PVI, no ablation strategy used alone or in combination during the redo procedure appears to be superior in improving arrhythmia-free survival. Left atrial size is a significant predictor of ablation outcome in this population.

Background The pathophysiology of persistent atrial fibrillation (AF) remains unclear. While several studies have demonstrated an association between myocardial infarction and atrial fibrillation, the role of stable coronary artery disease (CAD) is still unknown. As a result, we aimed to assess the association between CAD obstruction and AF recurrence after persistent AF ablation in patients with no history of CAD. Materials and methods This observational retrospective study included consecutive patients who underwent routine preprocedural cardiac computed tomography (CCT) before persistent AF ablation between September 2015 and June 2018 in 5 European University Hospitals. Exclusion criteria were CAD or coronary revascularization previously known or during follow-up. Obstructive CAD was defined as luminal stenosis ≥ 50%. Results All in all, 496 patients (mean age 61.8 ± 10.0 years, 76.2% males) were included. CHA2DS2–VASc score was 0 or 1 in 225 (36.3%) patients. Obstructive CAD was present in 86 (17.4%) patients. During the follow-up (24 ± 19 months), 207 (41.7%) patients had AF recurrence. The recurrence rate was not different between patients with and without obstructive CAD (43.0% vs. 41.5%, respectively; P = 0.79). When considering the location of the stenosis, the recurrence rate was higher in the case of left circumflex obstruction: 56% vs. 32% at 2 years (log-rank P ≤ 0.01). After Cox multivariate analysis, circumflex artery obstruction (HR 2.32; 95% CI 1.36–3.98; P < 0.01) was independently associated with AF recurrence. Conclusion Circumflex artery obstruction detected with CCT was independently associated with 2-fold increase in the risk of AF recurrence after persistent AF ablation. Further research is necessary to evaluate this pathophysiological relationship.

Background Ethanol infusion has recently been described as a curative strategy for certain peri-mitral flutters by blocking electrical conduction across the mitral isthmus along with the Marshall bundle. The present case showed that a right jugular vein approach, less described, may be a good choice when performing an ethanol infusion in the vein of Marshall (VOM). Case summary A 45-year-old man was admitted to our unit for dyspnoea associated with an atypical atrial flutter with a cycle length of 320 ms. The left atrial activation map showed a peri-mitral counter-clockwise circuit. The atrial flutter cycle length went up to 345 ms once an endocardial and epicardial point-by point-ablation of the mitral line was completed. At this stage, a new activation map showed that the mitral line was still permeable with an epicardial conduction bridge through the VOM. We decided to use an ethanol infusion for the ablation of the VOM. The coronary sinus could not be thoroughly catheterized due to a winding and angular shape so we decided to try a right jugular vein approach. A total of 9 mL of ethanol was injected into the VOM. A final venogram showed the diffusion of ethanol around the VOM. Sinus rhythm was restored during the last ethanol infusion. A new voltage map confirmed the completion of the mitral line, and we confirmed the bidirectional block. Discussion The present case showed that a right jugular vein approach may be a good choice when catheterizing and performing an ethanol infusion in the VOM.

We present the case of a 58-year-old patient admitted for wide QRS tachycardia (200 bpm). There was no delta wave on a 12-lead surface electrocardiogram during sinus rhythm. During the electrophysiological study, stimulation of the high right atrium and the proximal coronary sinus resulted in decremental anterograde conduction through the atrioventricular node, whereas pacing at the right ventricular apex led to retrograde conduction through the atrioventricular node. Conduction through an anterograde accessory pathway was revealed during pacing at the distal site of its atrial insertion. Some nonmanifest accessory pathways may be unmasked by differential pacing maneuvers.

Typical atrioventricular nodal reentrant tachycardia (AVNRT) is the most common regular supraventricular arrhythmia in humans; the anatomical site of the circuit and the nature of the pathways involved has been described for a long time. Complete atrioventricular (AV) block during AVNRT is a rare but well-known condition.1,2 To date, the site of the 2:1 block has not been well characterized. Usually, the presence or absence of a His bundle potential (HBP) in blocked beats is helpful in determining whether the block is occurring within or below the AV node.

We report a case of a 19-year old man with incessant right atrial tachycardia (AT) resulting in severe biventricular systolic dysfunction.Successful catheter ablation was obtained by cryo-energy applications at two right atrial exits and it was followed by full recovery of ventricular contractility at 3 months evaluation.

Cardiovascular disease accounts for 43% of all deaths in patients with endstage renal disease, and CVD continues to remain the leading cause of mortality and morbidity following renal transplantation. However, the characteristics and the hospital mortality of acute myocardial infarction (AMI) in patients with kidney transplantation (KT) remain to be determined in large scale study. From the French nationwide hospital medical information database, all the consecutive patients hospitalized in the 1546 French hospital/clinics for AMI from 1st January 2005 to 31st December 2009 were included. We compared the specific profile and the hospital mortality of patients with KT to patients without renal failure. Patients with personal past history of renal failure and/ or dialysis were excluded. Among the 329 839 patients with AMI included, 404 (0.1%) patients were after KT. Patients with KT were more frequently men (78.7 vs 66.8%, with p<0.001), markedly younger (58±12 vs 68±11, with p<0.001), and les smoker (5.0 vs 9.1%, with p<0.001) than patients without KT. There was also a higher proportion of hypertension (28.5 vs 23.4%, with p0.017) and a lower proportion of STEMI (75.7 vs 82.7%, with p<0.001) in patients after KT. More than two-thirds of AMI complicating post KT period occured before discharge (67.1%) and 91% in the first year after KT. After adjustment for age, sex and STEMI, in-hospital mortality was higher in KT group (4.2 vs 2.9%), but with p=0.210. From our large scale nationwide study, our work demonstrated that patients with KT complicated by AMI are markedly younger with a specific difference for usual risk factors, but transplant-related risk factors explain also this specificity. We highligts that AMI occurs very early after KT, most often before discharge. To decrease the frequency of MI following renal transplantation, screening of coronaropathy and evaluation of risk factors before KT, as well as after KT must be evaluated.

Iatrogenic complications are defined as adverse reactions that can be induced by non pharmacological cause, including cardiac devices or stimulation techniques. The use of cardiac devices has considerably increased over the last decade. However, only few data are available on non pharmacological iatrogeny (NPI) as cause of admission in coronary care unit (CCU). In patients admitted in CCU for iatrogenic, we aimed to determine the prevalence, characteristics and outcomes of NPI. From 1st April 2008 to 31st December 2013, all the consecutive admissions at the coronary care unit caused by NPI defined as pacemaker (PM), Implantable Cardioverter Defibrillator (ICD), radiofrequency ablation (RFA), coronary angiography, valve surgery or transcatheter aortic valve implantation (TAVI) and any other cardiac procedure were prospectively included. Patients with NPI were compared with the other patients. Among the 11503 patients admitted in CCU over the inclusion period, 225(2%) had NPI. The major cause of admission was conduction disturbance, and acute coronary syndrome or dissection (figure).The most frequent origin was coronary angiography (25%), valve intervention (22%), PM (19%), ICD (18%). The number and rate of admission for NPI markedly increased from 2008(n= 15(1,1%)) to 2013(n=52(2,6%)). This trend was mostly linked to the increase between 2008 and 2013 in new devices such as ICD (n=4 vs n=10), TAVI (n=0 vs n=4) and RFA (n=0 vs n=2). The intra-hospital mortality was stable during this period for the overall patients and patients with NPI (8% and 7%). Non pharmacological iatrogeny represents a non-negligible cause of admission in CCU, characterized by a increased rate of complications due to new techniques over the last 5 years. Multicentric studies are needed to investigate this public health issue. Download : Download full-size imageAbstract 0121 – Figure Abstract 0121 – Figure

The aims of our study were to assess ventricular tachycardia or fibrillation (VT or VF) occurrence after AMI and to analyse the relationship with either symptomatic or silent AF occurrence. Silent or symptomatic AF are known to be common after AMI and to impair patients prognosis. But the reasons of this worse prognosis remain discussed. 849 consecutive AMI were prospectively analyzed by continuous ECG monitoring (CEM) during the first 48 hours after admission. All AF, VT or VF episodes were confirm by standard ECG and sytematically reviewed by two investigators. The population was studied into three groups: No AF, Silent AF, and symptomatic AF after AMI. Forty five patients (5%) developed symptomatic AF and one hundred and thirty five developed silent AF (15.9%). Compared with the no AF group, patients with AF were markedly older 80 (67-85) and 81(71-88) vs. 62 (53-75) years; with p<0.001), more likely to have hypertension (96(72%) and (35(80%) vs 332(50%); with p<0.001) and less smoker (26 (20%) and 3(7%) vs. 242 (36%); with p<0.001). Comparing these three groups at day 1 and day 2, patients with symptomatic AF had higher heart rate (maximum, median or minimum) than patients with silent or no AF. Thus, at day 1 there was trend to a higher rate of VT or VF occurrence in symptomatic AF group, that was confirm at day 2 with 11(24.4%) vs 7(5.2%) in silent AF group and 29(4.3%)in no AF group, with p<0.001. Moreover, in-hospital mortality was higher in symptomatic AF group (8 (17.8%)) than in silent AF group (14 (10.4%)) and in no AF group (9 (1.3%)) with p<0.001. Symptomatic AF is very common after AMI and impacts patient’s outcome with more frequent episodes of VT or VF and higher inhospital mortality (17.8%). Our large prospective study suggests that VT or VF occurrence associated with symptomatic AF could be linked with the higher mortality in this population.

Coronary Artery Anomalies (CAA), including anomalies of coronary origin (ANOCOR) and ectasia or coronary aneurysms (ECTACOR) share common entities. In coronary angiographies or autopsy series, their prevalence range from 0.2 to 1.5%. Case control studies reported an association between CAA and acute myocardial infarction (MI). We aimed to analyze their prevalence, characteristics, therapeutic strategies and prognosis in patients with acute MI. All the consecutive patients admitted in the intensive care unit of our hospital who underwent coronary angiography for an acute MI from 2001 to 2013 were retrospectively analysed. Among the 9393 patients included during the study period, 80(0.92%) CAA were identified, including 37 (46%), ANOCOR and 43 (54%) ECTACOR. Most were male (86%), with a mean age at 61±14 y, and 2.1±1.4 risk factors. The most frequent localisation of ANOCOR was the circumflex artery (65%). The abnormal artery corresponds to the culprit lesion in 30% of cases, and 46% had significant stenosis. In contrast, ECTACOR were mainly localised on the right coronary artery (58%), and correspond to the culprit lesion in 70% of the cases, and 60% had a significant stenosis. A minority, i.e. 41% of the significant lesions found on ANOCOR and 31% of those on ECTACOR, received only a medical treatment, while 47% and 58% were stented, or 12% and 12% underwent Coronary Artery Bypass Surgery, respectively. After Percutaneous Coronary Intervention (PCI), final flow was TIMI 3 in most cases (94% and 81%, respectively). Only one patient died during the hospital stay. In our large retrospective study, the prevalence of CAAs is consistent with older angiographic series. Culprit lesion was more frequently associated with ECTACOR, but not with ANOCOR. The majority of significant lesions was treated by coronary stenting with a successful angiographic result.

Le risque de syndrome coronaire aigu (SCA) est augmenté chez les transplantés rénaux mais le profil et la mortalité hospitalière restent à déterminer. Dans ce travail, nous avons étudié les caractéristiques et la mortalité hospitalière de ces patients au cours du SCA. À partir de la base de données nationale française d’information médicale (PMSI), tous les patients admis pour SCA dans les 1546 structures de soins répertoriées en France, du 1er janvier 2006 au 31 décembre 2011, ont été analysés. Nous avons comparé les caractéristiques des SCA, regroupant les infarctus du myocarde avec sus-décalage du segment ST (STEMI) et les infarctus du myocarde sans sus-décalage du segment ST (NSTEMI), chez les greffés rénaux par rapport à la population générale. Les patients aux antécédents d’insuffisance rénale chronique préterminale et/ou dialysés ont été exclus. Parmi les 329 839 patients inclus, 404 (0,9 %) transplantés rénaux ont fait un syndrome coronaire aigu (SCA). On dénombre 318 hommes (78 %) contre 220 470 (66 %), d’âge moyen 58 ans chez les patients greffés, contre 68 ans dans la population de référence (p < 0,0001). Les transplantés étaient deux fois moins fumeurs (5 % contre 13 %, p < 0,0001), plus hypertendus, diabétiques et artéritiques (28 %, 13 % et 2,5 % contre 22 %, 9 % et 1 % respectivement, p < 0,05). La mortalité hospitalière était supérieure chez les patients transplantés mais non significative (4,2 % versus 2,9 %, p = 0,21). Enfin, 67,1 % des SCA se produisent au cours de l’hospitalisation initiale après la transplantation, et 91 % au cours de la première année. Les transplantés rénaux sont plus à risque de SCA que la population générale avec une mortalité hospitalière qui tend à être augmentée. L’incidence de SCA, d’emblée maximale le premier mois qui suit la greffe, suggère de prêter la plus grande attention à l’état coronarien avant transplantation, en particulier chez les sujets de plus de 50 ans, incluant les non-diabétiques.