bluuebunny/crossref_metadata_2025 huggingface dataset:
P1021Low incidence of atrial tachycardia following ablation of low voltage areas in sinus rhythm for persistent atrial fibrillation
Authors: Lepillier A , Copie X , Escande W , Niro M , Paziaud O , Piot O
Published: June 2020

.  Background: Dedicated ablation strategies for persistent atrial fibrillation (AF) have shown a limited success rate with frequent atrial tachycardia (AT) occurrence. Recent studies suggest that atrial arrhythmogenic sites are related to tissular heterogeneities and increased fibrosis can be identified as reduced bipolar voltage areas.

. Purpose: Targeting low voltage areas (LVA) in addition to PVI may represent an efficient strategy for the ablation of persistent AF, and may limit the risk of AT recurrence.

. Methods: We prospectively included consecutive patients with symptomatic persistent AF. The ablation strategy consisted of the following steps: circumferential pulmonary vein isolation (CPVI), Sinus rhythm restoration by electrical cardioversion, voltage map performed in sinus rhythm. Complementary RFA was guided by low voltage areas (0.2-0.4 mV). Success was defined as freedom from AF/ atrial flutter or atrial arrhythmia at 12 months or more.

. Results:  101 patients (mean age: 62.5 +/- 10.4 years, men 73%) were included with persistent AF or long standing AF (7%). Procedure time was: 154 ± 25 min and fluoroscopy time: 184 ± 90 sec. Time of RFA was 44.7 +/- 12 min. Mean LA volume was 182 +/- 38 mL. LVA were found in 50 patients (49.5%). The distribution of these areas was:  30 anterior wall 29.7%), 21 septum (20.7%), 19 roof (18.8%), 5 inferior (4.9%), 11 left appendage (10.8%), 6 posterior (5.9%), 3 mitral isthmus (3%). RF ablation was realized for all LVA and homogenisation was attempt. After a single procedure at a mean FU of 12 months, 72.3% of patients were free of symptomatic AF. 27 patients had recurrence of atrial AF: 7 permanent, 15 persistent and 5 paroxysmal AF. Predictive factors of recurrence of AF were: long standing persistent AF, large left atrial volume (> 205 mL), shorts AF cycle length (< 168 ms) and reduce LEVF (< 45%). Atrial tachycardia occurred in 5 patients (4,9%). Mechanisms of AT were: typical cavo-tricuspid flutter in one patient, peri-mitral flutter in 2 patients, and atrial focal tachycardia (close to pulmonary veins) in 2 patients.

. Conclusion: These results suggest that PVI with complementary RF ablation guided on low voltage areas is an efficient strategy for symptomatic persistent AF, and reduce the recurrence of AT following this ablation strategy.
P563Hemoptysis after cryoablation for atrial fibrillation
Authors: Kumar N , Aksoy I
Published: June 2020

Aim

Cryoballoon is a widely used tool for ablation for atrial fibrillation (AF). There are several complications after cryoablation. This paper assesses the incidence rate and severity of hemoptysis after cryo ablation for AF.

Methods

For current systemic review and meta-analysis, literature has been reviewed from 2008 to 2019 focusing on the incidence of hemoptysis after cryoballoon ablation for atrial fibrillation catheter ablation in PubMed, Cochrane library and EMBASE databases.

Results

This meta-analysis included 3534 patients from 20 studies; of mean age 54.0 ± 10.9 years. All patients had cryoballoon ablation for paroxysmal or persistent AF refractory to treatment and follow up duration for 8.2 ± 5.9 months with mean procedure duration of 153.4± 65.4 minutes. The mean cryoablation duration was 869.4 ± 148 sec with mean temperature of -59.7 ± 5.1 °C and a total of 109 patients (3.08%) had hemoptysis which was mild in the majority of cases (76.1%), mild to moderate in 20.2% and severe in only 3.7%.  Hemoptysis onset was at 29.0 ± 56.5 day with median of 7 days, range (2 hours to 210 days). In 11 studies hemoptysis occurred early in 51 patients (95% CI for I2 was 0.0% to 0.0, P =0.95, I2 was 0.0%), but in 9 studies, hemoptysis occurred late in 58 patients (95% CI for I2 was 0.0% to 0.0, P =0.96, I2 was 0.0%).

Conclusion

Mild hemoptysis is experienced by significant number of cryoballoon AF ablation patients and severe type in 3.5 % attributed to significantly lower temperature in inferior pulmonary veins and is more often associated with bigger cryoballoon.

Abstract Figure. Overview of the manuscripts selection
P959Influence of complex reentrant atrial circuits on tachycardia cycle length
Authors: Alonso C , Rodriguez Font E , Guerra Ramos J , Campos Garcia B , Moreno Weidman Z , Mendez Zurita F , Mogro J , Garcia Mancebo S , Espinosa Viamonte H , Gonzalez Matos C , Maldonado Chavez J
Published: June 2020

Funding Acknowledgements

NA

OnBehalf

NA

Background

Ablation of left atrial reentrant tachycardias (ART) is challenging since they usually occur in the setting of complex diseased atrial tissue either in patients with structural heart disease or after ablation of atrial fibrillation. In these cases, scarred tissue or previous ablation lines make the circuits more complex. We have developed a mapping approach in which an activation map that only contains the active circuit is generated from entrainment maneuvers.

Purpose

To describe the electrophysiological characteristics of the circuits in patients with structural heart disease and previous left atrial ablation.

Methods

Consecutive patients with documented atypical flutter were included. A high density activation map was generated during the index arrhythmia and subsequently, entrainment maneuvers were performed to delineate the active circuit.

Results

Seventeen patients (82% males, average age 62+-7 years, 59% structural heart disease and 53% with a previous left atrial ablation) underwent 20 procedures. Twenty-one circuits were identified (20 in the left atrium and 1 in the right atrium).  Of all LA circuits, 15 were macroreentrant (8 roof dependent, 4 perimitral and 3 related to a gap after AF ablation. Four out of 5 microreentrant circuits were related to the left atrial appendage and 1 was identified in the septum. Overall, procedural duration and fluoroscopy time was 176 ± 55 minutes and 27 ± 13 minutes, respectively. Roof-dependent ARTs and gap-related ARTs after AF ablation exhibited a significantly longer TCL (359 ± 99 ms and 331 ± 47 ms, respectively, p < 0,05) than perimitral, microreentrant and RA circuits (279 ± 50 ms; 277 ± 36 ms; and 260 ms, respectively). Extensive areas of low voltage (<0.3 mV) were identified in all patients with LA circuits.

Conclusions

The cycle length of complex atrial reentrant tachycardias is apparently related to the location and characteristics of the circuits. This feature can be of help at the time of approaching the mapping and ablation of this tachycardias.
P955Non-invasive mapping: what is the minimal number of electrodes needed to obtain a good spatial resolution of the activation map?
Authors: Parreira A L , Carmo P , Adragao P , Nunes S , Pinho J , Budanova M , Zubarev S , Goncalves P , Ferreira A , Cavaco D , Marques H
Published: June 2020

Introduction and aims

The 12-lead ECG is highly inaccurate for localization of the site of origin of supraventricular and ventricular arrhythmias.  Non-invasive mapping systems (ECGI) based on a high number of electrodes recording the electrical activity on the surface of the torso have already proven good accuracy for mapping different arrhythmic substrates. The aim of this study was to assess what is the minimal number of leads needed to obtain a precise mapping with the ECGI.

Methods

This study enrolled 14 patients (9 male, median age 50 (44-58) years) referred to our center for catheter ablation of premature ventricular contractions (PVC). Patients underwent pre-procedural ECGI using the epicardial and endocardial mapping system . This system uses the DICOM images from contrast computed tomography of the heart and up to 28 adhesive electrodes with 8 leads each, adding up to 224 body-surface leads. All patients underwent invasive electroanatomical mapping and ablation with the magnetic navigation system. We analysed the number of recording leads used to construct the non-invasive activation map of the PVCs and the accuracy and the spatial resolution of the map when comparing to the invasive map. We then reprocessed the exam, using progressively less leads until we only left the leads placed in the standard 12 lead ECG positions and evaluated the concordance with the invasive map as well as the spatial resolution. We considered an earliest activation site (EAS) area of 1 cm2 a good spatial resolution and using a ROC curve we calculated the minimal number of leads necessary to obtain a good spatial resolution.

Results

The median number of electrodes used for the initial map was 170 (138-177). Concordance between non-invasive and invasive site of origin occurred in 11 out of 14 patients. The results are presented in the Table. The minimal number of electrodes to have a good spatial resolution was 100. The area of EAS was significantly lower when using more than 100 leads, respectively 0.65 (0.5-1) cm2 versus 3 (1.6-5) cm2, p < 0.001.

Conclusions

The minimal number of leads to achieve a good spatial resolution was high.  Reducing the number of leads resulted in a significant decrease in spatial resolution and a lower concordance rate.

ECGI data Number of adhesive electrodes Median number of leads Amycard/Carto concordance Median area of EAS in the ECGI (cm2) Maximal nº electrodes 170 (138-177) 11/14 0.64 (0.5-0.9) 12 electrodes 76 (61-80) 11/14 1.6 (1.4-2.6) 6 electrodes (2 Ant, 2 Lat ,2 Post) 38 (32-44) 9/14 4.3 (3.2-5.4) 12 leads 12 0/14 - Ant anterior; Lat: lateral; Post: posterior; EAS: early activation site.

Abstract Figure. Area of EAS according to the N of leads
P457Incidence of LA fibrosis and substrate-based AF ablation success rates in HF patients
Authors: Kirstein B , Neudeck S , Kronborg M B , El-Armouche A , Gaspar T , Piorkowski J , Wechselberger S , Zedda A , Tomala J , Mayer J , Wagner M , Ulbrich S , Richter U , Huo Y , Piorkowski C
Published: June 2020

Funding Acknowledgements

The author(s) received no specific funding for this work.

Background

In heart failure (HF) patients, sinus rhythm maintenance after catheter ablation for atrial fibrillation (AF) is mandatory to achieve better long-term outcome. Presence of left atrial (LA) fibrosis significantly attenuates ablation success rates. Incidence of LA fibrosis and the effect of an individualized substrate-based ablation concept on rhythm outcome in HF patients with AF is unclear.

Methods

This study investigated 103 patients (64 years, 69% men) with persistent AF (79%) and left ventricular (LV) dysfunction (EF 33% IQR [25; 38]) undergoing first time AF ablation. Identification of LA fibrosis and selection of ablation strategy were based on sinus rhythm voltage mapping. All patients received pulmonary vein isolation (PVI). LA fibrosis ablation was individualized by (i) homogenization of small areas, (ii) linear lesions connecting fibrosis and anatomical obstacles and (iii) linear lesions isolating large fibrotic areas. Rhythm outcome was measured by continuous device monitoring (AF detection ≥ 6 min) or Holter-ECG. A total post-procedural AF burden < 0.1% was defined as successful rhythm control.

Results

LA fibrosis in the overall cohort, in paroxysmal and persistent AF patients was detected in 39/103 (38%), 6/22 (27%) and 33/81 (41%), respectively. After 11 ± 5 months and 1.2 procedures/patient, freedom from AF recurrence was similar between patients with and without LA fibrosis (33/39 (84%) vs. 54/64 (84%); p = 0.485). With continuous monitoring, 73/87 (84%) patients recorded a total AF burden < 0.1%. There was no significant difference in AF burden outcome between patients with and without LA fibrosis (3.1% SD ±17.4 vs. 2.2% SD ±8.1; p = 0.4). No correlation between presence or extent of LA fibrosis and AF burden was found; p = 0.299.

Conclusion

A substantial number of HF patients with AF have no evidence of LA fibrosis. Among HF patients with LA fibrosis, individualized substrate-based AF ablation beyond PVI was able to achieve similar ablation success.
P1152Health-related quality of life among implantable cardioverter defibrillator patients compared to age- and sex-matched norms
Authors: Magnusson P , Karlsson J , Wallhagen M , Mattsson G
Published: June 2020

Background The decision to implant an ICD integrates presumed health-related quality of life (HRQL).

Purpose To assess HRQL in ICD patients using the questionnaire SF-36, and compare it to a Swedish age- and sex-matched population.

Methods SF-36 of ICD patients 2007-2017 (response rate 77.2%) were analysed using the Mann-Whitney U-test and effect size (ES).

Results In total, 223 patients (mean age 71.1 ±9.7 years) were included of whom 33.6% had a CRTD. A majority were men 82.1% (n = 183) and 60.1% (n = 134) had an ICD due to primary prevention. SF-36 score are summarized as Table 1. Mean age was similar between men and women (71.1 vs 70.9 years) and there were no significant difference score at any domain, including both component scores. Primary and secondary prevention patients (mean age 70.3 vs 72.3 years) scored similar except for worse GH in PP (p = 0.016, ES 0.35). A history of atrial fibrillation at baseline was associated with worse PF (ES 0.41) and PCS (ES 0.38). Neither appropriate therapy, inappropriate shock, nor complications requiring surgery, were associated with lower scores in any domain. In primary prevention due to ischemic vs non-ischemic cardiomyopathy no domain were significantly different. PCS decreased with higher age strata (p = 0.002) in contrast to MCS (p = 0.986).

Conclusion Patients with ICDs have lower physical and mental HRQL than age- and sex matched norms; however the effect sizes are small. HRQL is similar regardless of sex, primary vs secondary prevention indication, appropriate therapy, inappropriate shock or complications but decreases with age.

Table 1. SF-36 ICD patients(n = 223) Swedish Norms (n = 171) Mean (SD) Mean (SD) p-value Effect size Physical Functioning (PF) 65.1 (28.1) 75.5 (26.0) 0.0002 0.38 Role Physical (RP) 56.9 (44.1) 66.7 (40.4) 0.0466 0.23 Bodily Pain (BP) 71.9 (29.9) 71.0 (27.2) 0.6395 NS General Health (GH) 56.2 (21.7) 65.9 (25.3) ≤0.0001 0.41 Vitality (VT) 58.0 (24.8) 68.1 (27.2) ≤0.0001 0.39 Social Functioning (SF) 80.1 (24.4) 85.9 (22.9) 0.0025 0.25 Role Emotional (RE) 72.2 (39.9) 76.7 (35.7) 0.3730 NS Mental Health (MH) 76.2 (19.4) 83.8 (20.9) ≤0.0001 0.38 Physical Component Summary (PCS) 40.7 (12.3) 44.4 (11.6) 0.0052 0.31 Mental Component Summary (MCS) 48.6 (10.8) 51.9 (10.5) 0.0010 0.31 Health-related quality of life among ICD patients compared to age- and sex-matched Swedish norms.
P1033Cryo-ablation vs radiofrequency ablation: is there a difference between the two technologies - A single centre analysis of the sites pulmonary vein reconnection
Authors: Sidhu B , Antoun I A , Mistry A M , Vali Z V , Pooranachandran V P , Li X L , Newton M N , Ng G A N
Published: June 2020

Funding Acknowledgements

Nil

Introduction

Pulmonary vein isolation (PVI) remains the most common initial ablation strategy for management of atrial fibrillation (AF). The two main methods of creating these lesions include cryo-ablation or radiofrequency ablation (RFA). In both methods, gaps in the encircled lesions have the potential to cause recurrences of AF. The aim of this analysis was to determine whether there is a difference in the number of gap lesions when comparing cryoablation to RFA.

Methods

A retrospective single tertiary centre analysis was performed in 1152 patients who had an AF ablation between January 2015 to June 2019. Patients who required a redo-PVI were included for analysis (n = 155). Demographic (gender, age), clinical (BMI, type of AF, hypertension, DM, left atrial volume) and procedural (PVI method, fluoroscopy time, procedural time) data was collected. For the redo cases, the number of gap lesions by region were analysed by looking at electromechanical maps to determine where the most common gaps occurred for both technologies  

Results

A total of 155 redo procedures (Cryo-RF, n= 46, RF-RF, n = 109) were analysed. There was no statistically significant difference or linear correlation between being obese and number of gaps in the cryo-RF or RF-RF group (R = -0.042, p = 0.351, R = 0.153, p = 0.110 respectively). The total number of gaps in the in the Cryo-RF group = 232 and RF-RF group = 564. There was no significant difference between the two groups (p = 0.963). There was no significant difference or correlation between the use of contact force and the number of gaps in the RFA group (p = 0.644, R = -0.045).

Conclusion

Each of these PVI technologies have previously been found to be effective in treating AF. Avoiding gaps  during PVI remains challenging. This retrospective analysis has demonstrated that overall there is no difference in the number of gap lesions that occur after using either of these current ablation technologies.

Cryo-RF vs RF-RF: group comparison CRYO-RF (n = 46) RF-RF (n = 109) P Value Male (%) 28 (60.1) 80 (73) 0.197 Age at 2nd procedure (mean +/- SD) 61.5 +/- 8.9 59.8 +/- 11.6 0.008 Time between procedures (days - mean +/- SD) 497.5 +/- 228.2 1007.7 +/- 924.8 <0.001 Obese (%) 17 (37) 58 (53) 0.073 LA volume (ml/m2 - mean +/- SD) 59.6 +/- 23 57 +/- 26 0.996 Contact force used in index procedure (%) 68 (62) 0.644 Total number of gaps 232 564 0.963 Table representing difference between and significance level for Cryo-RF and RF-RF groups.
P391Estimated glomerular filtration rate levels and risk of stroke in individuals with diabetes mellitus and atrial fibrillation
Authors: Westreich R , Barrett O , Kezerle L , Leventer Roberts M , Avgil Tsadok M , Akriv A , Ohana R , Feldman B , Haim M
Published: June 2020

Funding Acknowledgements

pfizer

Background

Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Chronic kidney disease (CKD) has been shown in some studies to increase the risk of stroke. This finding is not consistent among all studies. Therefore the relationship between kidney function, diabetes and stroke risk is complex and warrants further investigation.

Purpose

To assess the incidence rates and risk of ischemic stroke and mortality by baseline Estimated Glomerular Filtration Rate (eGFR) levels among individuals with AF and DM.

Methods

A prospective, historical cohort study using our electronic medical records database. The study population included all members 21 years old, with a first diagnosis of NVAF between January 1, 2010 to December 31, 2016 and a minimal follow-up period of 1 year. Among those patients identified as diabetics, we compared three groups of patients according to eGFR levels at the time of AF diagnosis: eGFR ≥ 60, between 30-60 and ≤ 30 or chronic dialysis or kidney transplant.

Results

A total of  17,567 cases were included in the final analysis, of them, 11013 (62.7%) had eGFR ≥ 60, 4930 (28%) with eGFR between 30-60 and 1624 (9.24%) with eGFR ≤30 . The median age was 75 years (IQR 65-83) with a majority of females in all groups, 52.5%, 51.2% and 55.5% respectively. The incidence of stroke per 100 person-years in the three study groups was: 1.88 in patients with eGFR ≥ 60, 2.69 in patients with eGFR between 30-60 and 3.34 in those with eGFR ≤ 30 . Impaired renal function was associated with increased risk of stroke in univariate analysis, but not found in the adjusted model  (Adjusted Hazard Ratio (AHR) = 1.04 {95% 0.89-1.23} for eGFR 30-60  and 1.16 {95% CI 0.88-1.51} for eGFR ≤ 30 compared to GFR ≥ 60). incidence of mortality per 100 person-years was 10.78 in patients with  eGFR ≥ 60, 21.49 in patients with eGFR 30-60 and 41.55 in those with eGFR ≤ 30. In both univariate and multivariate analyses, decreased levels of eGFR were associated with increased mortality risk compared to subjects with normal renal function (AHR 1.22 {95%CI 1.14-1.27} and AHR 2.09 {95%CI 1.95-2.24} for eGFR between 30-60 and for eGFR ≤ 30, respectively).

Conclusion

In this observational prospective cohort of patients with newly diagnosed NVAF, impaired renal function was not found to be associated with increased risk of stroke. Lower eGFR levels were associated with an increased mortality risk.
838Premature Cardiac Conduction Disease in families, potential role for Implantable Loop Recorder in screening? A Case Series
Authors: Sharif Z , Murphy L M , Al-Harbi K A H , Brennan C B , Connaughton H C , Green A G , Ward D W
Published: June 2020

OnBehalf

Cardiac Risk in the Young (CRY) Ireland

Background

  Cardiac conduction disease (CCD) is a potentially fatal entity. The spectrum ranges from benign clinical course to potentially precipitating sudden cardiac death. Permanent pacemaker (PPM) may benefit affected individuals but the genetic basis of CCD may be underestimated. No prior study has investigated the utility of screening relatives of victims of Sudden Arrhythmic Death Syndrome (SADS) with implantable loop recorders (ILR). 

Methods

 We describe 7 families referred to our inherited cardiac conditions service with a family history of SADS, in whom we identified premature CCD. ILR was utilized in screening the majority of families. 

Results

 Of 63 individuals screened, 31 (49%) had ILR insertion with 7 (11%) requiring PPM implant. 2/31 had normal baseline tests, and were identified post ILR implant. Other CCD not yet meeting clinical significance was detected in 10/31 (32%) individuals. These findings (documented 11 to 330 days post implant) included pauses of 3-5.8 seconds (n = 7), nocturnal bradycardia < 34 bpm (n = 2) and non-sustained polymorphic ventricular tachycardia. Of families undergoing mutation analysis, conventional genetic panels have been negative to date.

Conclusions

 Inherited premature CCD with variable penetrance may be an under-recognized cause of SADS.  To date 12/31 (39%) of individuals with ILR have findings suggesting inherited CCD. As inheritance pattern suggests autosomal dominant transmission, longer follow up may identify more affected individuals. Clinicians involved in SADS family evaluations should consider adding ILR implantation to routine assessment to improve diagnostic yield. We suggest a larger prospective study of consecutive families whose initial investigations following a SADS death have not identified a cause.

Summary of Findings Screening Abnormality Family 1 Family 2 Family 3 Family 4 Family 5 Family 6 Family 7 Bradycardia Yes Yes Yes Yes Yes Yes Yes PR >200 Yes No No No No No No <90% PTHR EST No No No No No No No Arrhythmia on EST Yes No No No No Yes No Pauses > 3s Holter/Telemetry Yes No Yes No Yes No Yes High grade AV block Holter Yes Yes No No No No No ILR: significant to date Yes Yes No No No No - ILR: findings to monitor Yes No Yes Yes No Yes - Provocation Testing No Negative No No No No No Genetics Negative Negative Awaited Awaited Awaited Awaited Negative PTHR predicted target heart rate, EST: exercise stress test
1326Identification of arrhythmic isthmus in patients with transposition of the great arteries treated with atrial switch surgery using a new high-definition wavefront-activation-orientation grid catheter
Authors: Francisco Pascual J , Llerena Butron S , Perez Rodon J , Santos Ortega A , Benito B , Rodriguez Garcia J , Dos Subira L , Pijuan Domenech A , Subirana M T , Miranda Barrio B , Roses Noguer F , Gonzalez Fernandez V , Ferreira Gonzalez I , Rivas Gandara N
Published: June 2020

INTRODUCTION

Patients with D- transposition of the great arteries (TGA) treated with Senning or Mustard surgeries have several atrial scars that predispose them to develop atrial tachycardias (AT). Identification of scar zones and possible arrhythmic isthmus in voltage mapping will help to guide the ablation.

AIM

To describe the feasibility of using a specific mapping catheter to identify possible arrhythmic isthmus in this set of patients.

METHODS

Prospective observational study in patients with history of SVT and atrial switch surgery, that underwent electrophysiologic study (EP) and electroanatomic (EA) mapping with a new 8Fr deflectable, multipoint wavefront-activation-orientation independent Grid catheter, in a third level hospital since April 2018 until May 2019, with medium-term follow-up.

RESULTS

A total of 8 EPs were performed in 7 patients (3 (57%) Female, median age 35 ± 6,3 y.o.). Figure 1A shows the localization and percentage of scar identified in both atria. A total of 6 AT were induced. In this, an arrhythmogenic isthmus was identified and, in all patients, at least one non-arrhytmogenic isthmus was documented. Figure 1B shows anatomical and electrophysiological characteristics of the isthmus. Arrhythmogenic isthmus had slower conduction velocity than non-arrhytmogenic ( mean 0,44m/s (IQI 0,17-0,62)  vs  1,05 m/s (IQI 0,86-1,39) p = 0.008) and fractionated potentials were detected more frequently (100% vs 50% p = 0.089)

CONCLUSION

EA mapping with a new a multipoint, high-definition, Grid Cather is feasible and allows the identification and electrophysiological characterization of arrhythmogenic and non-arrhytmogenic isthmus in patients with TGA treated with atrial switch surgery.

Abstract Figure 1
P947dST-Tiso index, a new shallow ECG marker in response to ajmaline for predicting ventricular fibrillation induction in Brugada patients
Authors: Iacopino S , Sorrenti P , Fabiano G , Campagna G , Petretta A , Pardeo A , Placentino F , Filannino P , Artale P , Santarpino G
Published: June 2020

Introduction - No study has been performed to investigate the role of drug-induced ECG morphology modifications as potential risk factors for the development of malignant arrhythmias in patients with Brugada syndrome.

Purpose - The aim of this study is to introduce a new index to improve asymptomatic patient stratification  and to report the first case of a patient with Brugada syndrome undergoing ajmaline testing that has been evaluated using a diagnostic 252-lead ECG vest.

Methods - From December 2018 to April 2019, 26 consecutive patients [mean age 39.9 (30–59) years, 18 male] with no cardiovascular risk factors underwent ajmaline testing. By evaluating ECG recordings after ajmaline administration, we calculated an index that we called "dST-Tiso", that is the duration of the positive component of the ST-T wave to the isoelectric line, in V1 and/or V2.

Results- Out of 26 patients, 16 (61.5%) had a positive test, with type 1 (coved-type) ECG diagnostic pattern in leads V1-V2 from the 2nd, 3rd and 4th intercostal spaces.  The mean recorded dST-Tiso value was 239 ± 76 ms. The ECG showed T-wave above the isoelectric line in 5 patients with a significantly higher dST-Tiso value (on average 360 ± 56 ms), and biphasic T-waves below the isoelectric line in 11 patients with a dST-Tiso value of 209 ± 42 ms (Mann-Whitney, p = 0.039). All patients with positive ajmaline test underwent programmed electrical stimulation (PES). Ventricular fibrillation was induced during PES in all 5 patients with stretched dST-Tiso. In the remaining 11 patients without stretched dST-Tiso, no ventricular arrhythmia was induced by PES.  Fig 1 Moreover, using non-invasive high-density electrocardiographic mapping (252-lead ECG vest), 3 patients with dST-Tiso positive pattern received a second ajmaline protocol, with assessment of both the depolarization and repolarization phases.

Conclusion - The ECG pattern of prolonged dST-Tiso seems to have a significant impact on safety during PES and may have potential for stratifying risk of sudden death in patients with PES-induced ventricular tachycardia/fibrillation.

Abstract Figure 1. Patients’ flowchart.
P1010Association between left atrial fibrosis detected by cardiac magnetic resonance and endocardial electroanatomic mapping in the evaluation of the electrophysiological substrate in atrial fibrillation
Authors: Caixal G , Alarcon F , Nunez M , Garre P , Soto D , Borras R , Gunturitz C , Perea R , Roca I , Guasch E , Mont L
Published: June 2020

Background

Atrial fibrillation (AF) is related to left atrial fibrosis, but its identification by late magnetic resonance imaging (LGE) with gadolinium (LGE) persists in controversy due to heterogeneous results in its correlation with the electroatomic map (EAM) and the difficulty of perform histological studies in humans.

Purpose

We try to examine the point-by-point association between high density EAM and LGE-MRI using an automatic and reproducible method.

Methods

A LGE-MRI was performed in 16 patients prior to ablation. Three different areas were established depending on the intensity of normalized enhancement for each patient according to their blood group with the image intensity ratio (IIR) (healthy <1.20, border area (BZ) ≥1.20 <1.32 and scar ≥1.32). The high density electroanatomic maps of the left atrium (LA) were projected onto the MRI, obtaining an automatic correlation point by point.

Results

The study obtained significant differences (p < 0.001) between voltage (mV) and CV (mm/ms) among healthy, BZ and scar areas, as well a significant inverse correlation (p < 0.001) between voltage and IIR (R=-0.39). It obtained too a significant correlation between CV and IIR (R=-0.24), but this showed a greater correlation in those patients who have the least dilated LA (p = 0.02).

Conclusions

LGE-MRI and EAM showed good correlation in delineating potential pathologic substrate in AF, but left atrium dilation could reduce the performance of the CMR in this task. Conduction velocity could be more sensitive than voltage and LGE-MRI to detect incipient substrate in AF.

Voltage and conduction velocity values Area /IIR Velocity (mm/ms) Voltage (mV) I / <.20 1.036(0.913-1.158) 1.593(1.489-1.696) 2 / ≥1.20 and <1.32 0.722(0.590-0.850) 0.792 (0.649-0,935) 3 / ≥1.32 0.623(0.473-0,733) 0.444(0.245-0.642) Voltage and conduction velocity values in the three areas of the LGE-RMN.

Abstract Figure. Correlation among voltage, VC and LA
P527Ultrasound-guided serratus anterior plane block for S-ICD implantation using the intermuscular technique
Authors: Migliore F , De Franceschi P , De Lazzari M , Miceli C , Crescenzi C , Migliore M , Iliceto S , Bertaglia E
Published: June 2020

Funding Acknowledgements

NONE

Background

operative anesthetic requirements and peri-operative discomfort are barriers to wide adoption of the subcutaneous implantable cardioverter defibrillator (S-ICD) system expecially when the intermuscular technique is used due to the greater amount of tissue dissection. The procedure is most commonly performed under general anesthesia (GA). There is growing interest in transitioning away from the routine use of GA and towards several alternative anesthesia modalities implifying the anesthetic management of the S-ICD implant procedure without the involvement of an anesthesiologist.

Purpose

we assessed the feasibility of ultrasound-guided serratus anterior plane block (US-SAPB) in patients undergoing S-ICD implantation with the intermuscular two-incision technique. Methods: the study population included 38 consecutive patients (84% male; median, 53 [46-62] years) who received S-ICD implantation using the intermuscular two-incision technique. All procedures were performed under US-SAPB and sedoanalagesia without the involvement of an anesthesiologist.

Results

the average procedure time was 67 ± 14 minutes.No patient experienced significant hemodynamic changes or oxygen desaturation during the period of US- SAPB procedure and sedation; there was no need for pharmacological interventions. The whole procedute was well tollerated without discomfort and complications in the absence of needing GA except in one (2.6%) patient who required GA with laryngeal mask airway. Patients remained always able to respond appropriately to neurological monitoring during S-ICD implantation procedure. There were no procedure-related complications.

Conclusion

US-SAPB and the intermuscular two-incision technique may be a safe and feasible promising combination for S-ICD implantation overcoming potential barrier to wieder S-ICD adoption in the clinical practice.
P1438Predictors and clinical impact of bleeding events after left atrial appendage closure in patients with high risk or a history of bleeding
Authors: Sano M , Fink T , Sciacca V , Vogler J , Saad M , Joost A , Heeger C-H , Eitel C , Keelani A , Langer H , Eitel I , Tilz R
Published: June 2020

Background

Left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation and may be especially attractive in patients with high risk or a history of bleeding. However, data of clinical benefit and incidence of post-procedural bleeding in patients with both high risk of bleeding and ischemic cerebral stroke after LAAC are lacking.

Objectives

This study sought to identify predictors and the prognostic impact of post-LAAC bleeding in patients at high risk and/or history of bleeding in the direct oral anticoagulant therapy (DOAC) era.

Methods and results

We retrospectively enrolled a total of 195 patients (75 ± 8.7 years, 38% female, 47% with previous major bleeding, mean CHA2DS2-VASc score 4.3 ± 1.6 and mean HAS-BLED score 2.7 ± 1.1) undergoing endocardial (91%) or epicardial (9%) LAAC during a mean follow-up of 339 ± 319 days. Twenty-three (11.9%) patients developed procedure-unrelated bleeding events after a median of 147 (43, 362) days after LAAC, in 12/23 (52%) patients under single antiplatelet therapy (SAPT), 6/23 (26%) dual antiplatelet therapy (DAPT), 1/23 (4%)  DOAC, 1/23 (4%) VKA, 2/23 (9%) dual therapy (SAPT and DOAC/VKA) and 1/23 (4%) triple therapy (DAPT and DOAC/VKA). (Figure) Diabetes mellitus and previous major bleeding were identified as the independent predictors of post-LAAC bleeding (Odds ratio 2.65 [95% CI:1.04-6.73], p = 0.041, and 5.50 [95% confidence interval:1.72-17.5], p = 0.004). Post-LAAC bleeding was associated with all-cause death (9/23 [39%] vs 18/171 [11%], p = 0.001), but not ischemic stroke/TIA (1/23 [4%] vs 6/171 [4%], p = 0.593) nor device thrombus (2/23 [9%] vs 3/171 [2%], p = 0.108). Kaplan-Meier curve estimated that patients with post-LAAC bleeding had a worse mortality than those without post-LAAC bleeding (3-year mortality; 35.6% [95%CI; 11.6-61.0%] vs 68.7% [45.0-83.8], p = 0.029)

Conclusions

In AF patients with high bleeding risk or history of bleeding undergoing LAAC, bleeding events are common and may occur even after long-term duration after LAAC. Previous major bleeding history strongly predicts subsequent bleeding events following LAAC and is associated with unfavorable mortality. Further investigations are required to identify optimal post-procedural antithrombotic strategies for patients undergoing LAAC with previous major bleeding.

Abstract Figure. The association between time to bleeding
P498External validation of a field termination-of-resuscitation rule for refractory out-of-hospital cardiac arrests in Japan
Authors: Goto Y , Funada A , Maeda T , Okada F , Goto Y
Published: June 2020

Background

A universal basic life support termination-of-resuscitation (BLS-TOR) rule was developed to identify patients with out-of-hospital cardiac arrest (OHCA) eligible for field termination of cardiopulmonary resuscitation (CPR). In Japan, however, emergency medical service (EMS) providers are not allowed field termination of CPR and must transport all patients with OHCA to hospitals, regardless of return of spontaneous circulation (ROSC). Therefore, we previously developed a Japanese TOR (JP-TOR) rule in the field for refractory OHCAs using data from the All-Japan Utstein registry between 2011 and 2015, when CPR was performed according to the 2010 guidelines. The JP-TOR rule recommends CPR termination when patients meet all the following criteria: initial asystole, unwitnessed arrest, age ≥81 years, no bystander interventions before EMS arrival, and no ROSC after EMS-initiated CPR for 14 min.

Purpose

To validate the JP-TOR rule using more recent data where CPR was performed according to the 2015 guidelines, comparing the relevance of JP-TOR rule with the BLS-TOR rule, which consists of the following criteria: no prehospital ROSC after 6-min EMS-initiated CPR, arrest unwitnessed by EMS providers, and no shock received.

Methods

We analysed the records of 242,184 patients (age ≥18 years) who experienced OHCA treated by EMS providers. Data were obtained from a prospectively recorded Japanese nationwide Utstein-style database from 2016 to 2017. The primary endpoints were specificity and positive predictive value (PPV) for predicting the 1-month mortality after OHCA with the JP-TOR and BLS-TOR rules.

Results

The overall 1-month survival rate was 5.3% (12,847/242,184). The proportions of patients with OHCA fulfilled the JP-TOR and BLS-TOR criteria were 10.4% and 89.3%, respectively. The specificity and PPV of the JP-TOR and BLS-TOR rules for predicting 1-month mortality were 99.5% (95% confidence interval [CI], 99.4%–99.5%) and 99.8% (95% CI, 99.7%–99.8%) and 44.7% (95% CI, 43.8%–45.5%) and 96.7% (95% CI, 96.6%–96.8%), respectively.

Conclusions

The JP-TOR rule for EMS providers treating patients with OHCA in the field was successfully validated using more recent data from a Japanese registry where CPR was performed according to the 2015 guidelines. The JP-TOR rule was superior to the BLS-TOR rule in Japanese EMS systems, having both high specificity and PPV of >99% for predicting 1-month mortality. The JP-TOR rule may help EMS providers decide whether to terminate resuscitation efforts for unresuscitable patients with OHCA in the field. Prospective validation studies and establishment of prehospital EMS protocol are required before implementing this rule in Japan.
P1384Radiation safety and electrophysiologists: radiation protection status
Authors: Krzowski B , Gawalko M , Peller M , Balsam P , Lodzinski P , Grabowski M , Opolski G , Kosiuk J
Published: June 2020

INTRODUCTION

 Ionizing radiation is typically used during variety electrophysiological (EP) procedures, although it may contribute to deterministic effects especially for staff. 

PURPOSE

 The purpose of this study was to perform an analysis of EP operators’ radiation protective devices for occupational exposure. 

METHODS

 Data reported herein were gathered from international, multi-site, prospective, Go 4 Zero Fluoroscopy registry. The registry encompassed 25 European EP centers, and up to 5 operators from each center. The presence of operators’ X-ray protection tools was examined to determine the level of operators’ protection. Additionally, the tests included availability of measures to decrease radiation output and exposure control measures. Finally, the analysis of correlation between the X-ray protection and degree of operators’ experience (<5, 5-15,>15 years) as well as number of procedures performed per month (1-9, 10-19, 20-39, >40 procedures/month) was performed. 

RESULTS

 Our analysis included 95 operators (median age: 39 years, 85% of male, median training time: 5 years). The whole study group performed annually medical examinations due to radiation exposure and 56% of them received dosimetry reports once a month, 5% - once every 3 months, and 39% - once a year. Irrespectively of experience or number of performed procedures the most frequently used X-ray protection tools (used by >80% of group) were lead apron, thyroid shields, screen below the table, glass in the lab, and least often (used by < 6% of group) – protective gloves and cabin. The most often exposure control measures used were chest (95%) followed by collar (31%), ring (24%) and eye (7%) dosimeters. The inverse correlation between level of experience and measures to decrease radiation output was observed (collimation: 84%, 80% and 78%; minimizing the tube-to intensifier distance: 100%, 93% and 91% of operators with <5, 5-15 and >15 years of experience, respectively). There were not observed differences between type of radiation protection equipment and operators’ level of experience or number of procedures. Additionally, there were no differences between male and female operators regarding protective equipment, expect eyeglasses or cabin that were more often used by men. Operators who were protected by >4 X-ray protection tools were exposed for higher radiation levels as compared to those protected by <4 X-ray protection tools (median [IQR] radiation exposure: 0.6 [0.2-1.1] vs 0.2 [0.1-0.2] mSv per month, p < 0.0001; 1.1 [0.1-12.0] vs 0.5 [0.1-1.1] mSv per year, p < 0.0001). There were no differences between the type of (universitary vs non-universitary) or institution’s localization (Eastern vs Central vs Western Europe) and used protective equipment.  

CONCLUSIONS

 Both proper radiation protective equipment, and regular medical examination due to professional exposure are mandatory to reduce radiation exposure in practice.
P1391Plasma aldosterone level in different forms of atrial fibrillation
Authors: Shevelyok A , Vatutin N
Published: June 2020

Background. Hyperactivation of the renin-angiotensin-aldosterone system plays a key role in the development of structural remodeling underlying the atrial fibrillation (AF). Nevertheless, the role of excessive aldosterone production in AF development has not been studied.

Purpose. The study aims to evaluate the aldosterone levels in different forms of AF and sinus rhythm.

Methods. The study included 130 patients (the main group) with non-valvular AF. Of these, 40 (30.8%) patients had permanent, 50 (38.4%) – persistent and 40 (30.8%) – paroxysmal AF. The control group consisted of 40 patients with cardiovascular pathology, who did not have a history of AF episodes. Plasma aldosterone levels were measured by immunoenzyme method. In patients with paroxysmal and persistent AF measurement was perfomed during AF episode before restoration of sinus rhythm. Aldosterone reference values was considered as 40-160 pg/ml.

Results. Aldosterone levels were significantly higher in patients of the main group compared to the control (141.5 ± 41.8 pg/ml vs 105.0 ± 33.1 pg/ml, P < 0.001). It was the highest in paroxysmal and persistent AF and lower – in permanent AF. Hyperaldosteronemia (>160 pg/ml) prevalence was significantly higher among all patients of AF group compared to the control (32.3% vs 7.5%, respectively, P = 0.004), however multiple comparisons showed significant differences between paroxysmal AF (47.5%) and sinus rhythm only.

Conclusion. Plasma aldosterone level is significantly higher in AF compared to sinus rhythm. In patients with paroxysmal and persistent AF it’s concentration is higher than in patients with permanent AF.
P1421Assessment of intraatrial conduction during staged catheter ablation of persistent AF
Authors: Kovalev A , Filatov A G , Kovalev S A , Bockeria L A
Published: June 2020

Goal. To evaluate the electrophysiological changes in the LA myocardium between the stages of sequential RFA of persistent AF.

Materials and methods. From 2015 to 2018 43 patients (27 men and 16 women) underwent sequential ablation (second intervention in a period of 3 to 6 months) of persistent AF. The routine isolation was performed in the first stage. During the second stage additional lesions were performed in the areas of the restored conduction and posterior wall isolation. All patients underwent a routine EP before each stage with measurements of the atrial myocardial refractory periods, as well as intraatrial conduction.

Results. The EP parameters before the first and second stages had significantly changed: refractory periods in the areas of previously performed RFA had increased from 184 (166; 208) ms to 212 (174; 249) ms, respectively, p <0.001, the dispersion of refractivity decreased from 34 (18; 48) ms to 21 (16; 29) ms, p = 0.017. According to ECG, the duration of intraatrial conduction also decreased by 34 (24; 51) ms, p = 0.034.

Conclusion. Electrophysiological markers of intra- and interatrial conduction show a tendency to reverse modeling of atrial functions in patients passing through the staged treatment of persistent AF.
P1050General anesthesia improved rate of first-pass pulmonary vein isolation by radiofrequency ablation in patients with atrial fibrillation
Authors: Narikawa M , Kiyokuni M , Kino T , Taguchi Y , Yano H , Hosoda J , Matsumoto K , Sugano T , Ishigami T , Ishikawa T , Tamura K , Kimura K
Published: June 2020

Background

Pulmonary vein isolation (PVI) with radiofrequency ablation (RFA) is one of the important procedures for atrial fibrillation (AF). Attaining the stability of RFA, respiratory management and pain control during the procedure are required.

Purpose

We compared the characteristic parameters and procedural outcomes between general anesthesia and moderate (conscious) sedation in patients with AF performed RFA.

Methods

We performed a retrospective, 2-center observational study to compare the general anesthesia with moderate sedation during RFA on AF from January 2018 until December 2018. In general anesthesia group, we administrated propofol and muscle relaxants under mechanical ventilation. In moderate sedation group, we administrated dexmedetomidine and/or propofol with analgesic drug. Procedural time of AF ablation, first-pass PVI (pulmonary vein isolation after completing the right or left circle) were assessed.

Results

A total of 98 patients with mean age 66 ± 11 years were enrolled (80 males, 81%). Of these, 19 patients were performed RFA under general anesthesia and 79 patients were performed under moderate sedation. Age, gender, BMI, medications before admission and CHADs2 score (general anesthesia:1.9 ± 1.2 vs moderate sedation:1.5 ± 1.1, p = 0.14), left atrium diameter (40.2 ± 6.2 vs 40.6 ± 6.8 mm, p = 0.81) and proportion of paroxysmal AF (47.4 vs 54.4%, p = 0.61) were similar between two groups. Our study found catheter RFA with general anesthesia to be associated with reduced procedural time (161 ± 29 vs 241 ± 58 minutes, p < 0.01) and improved the rate of first-pass PVI (left pulmonary vein: 84.2 vs 59.5%, p = 0.06 and right pulmonary vein: 84.2 vs 58.2%, p =0.04).

Conclusions

RFA under general anesthesia improved first-pass PVI (quality of PVI) and shortened procedural time. General anesthesia may attribute to attaining the catheter and patient stability during RFA for PVI.