Publications by authors named "Franck Molin"

25 Publications

  • Page 1 of 1

Twiddler Syndrome without Lead Dislodgment Discovered by Remote Monitoring.

Case Rep Cardiol 2021 6;2021:8816524. Epub 2021 Feb 6.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, Canada.

Twiddler syndrome is an uncommon yet dangerous phenomenon usually resulting in lead displacement with loss of capture of cardiac implantable electronic devices. In this case report, we present an interesting case of Twiddler syndrome without lead dislodgment which was detected by an alert triggered by an increase in impedance on remote monitoring.
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http://dx.doi.org/10.1155/2021/8816524DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884166PMC
February 2021

Ventricular Arrhythmia in Septal and Apical Hypertrophic Cardiomyopathy: The French-Canadian Experience.

Front Cardiovasc Med 2020 22;7:548564. Epub 2020 Oct 22.

Division of Cardiology, Multidisciplinary Cardiovascular Department, Institut Universitaire de Cardiologie et Pneumologie de Québec (IUCPQ-UL), Université Laval, Québec City, QC, Canada.

Apical hypertrophic cardiomyopathy (aHCM) is thought to have a more benign clinical course compared to septal HCM (sHCM), but most data have been derived from Asian cohorts. Comparative data on clinical outcome in Caucasian aHCM cohorts are scarce, and the results are conflicting. The aim of this study was to estimate the prevalence and outcome of aHCM in French-Canadians of Caucasian descent. We conducted a retrospective, single-center cohort study. The primary endpoint was a composite of documented sustained ventricular arrhythmia (VA), appropriate ICD therapy, arrhythmogenic syncope, cardiac arrest, or all-cause mortality. A total of 301 HCM patients (65% males) were enrolled including 80/301 (27%) with aHCM and 221/301 (73%) with sHCM. Maximal wall thickness was similar in both groups. Left ventricular apical aneurysm was significantly more common in aHCM (10 vs. 0.5%; < 0.001). The proportion of patients with myocardial fibrosis ≥ 15% of the left ventricular mass was similar between aHCM and sHCM (21 vs. 24%; = 0.68). Secondary prevention ICDs were more often implanted in aHCM patients (16 vs. 7%; = 0.02). The primary endpoint occurred in 26% of aHCM and 10.4% of sHCM patients ( = 0.001) and was driven by an increased incidence of sustained VA (10 vs. 2.3%; = 0.01). Multivariate analysis identified apical aneurysm and a phenotype of aHCM as independent predictors of the primary endpoint and the occurrence of sustained ventricular tachycardia. Unexplained syncope and a family history of sudden cardiac death were additional predictors for sustained VA. Apical HCM was associated with an increased risk of ventricular arrhythmia even when excluding patients with apical aneurysm. The phenotype of apical HCM is much more common in French-Canadians (27%) of Caucasian descent compared to other Caucasian HCM populations. Apical HCM in French-Canadians is associated with an increased risk for ventricular arrhythmia.
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http://dx.doi.org/10.3389/fcvm.2020.548564DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7642600PMC
October 2020

Findings of remote monitoring of implantable cardioverter defibrillators during the COVID-19 pandemic.

Pacing Clin Electrophysiol 2020 11 26;43(11):1366-1372. Epub 2020 Oct 26.

Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.

Background: Monitoring of cardiac implantable electronic devices was highly impacted by the COVID-19 pandemic considering the high volume of in-person visits for regular follow-up. Recent recommendations highlight the important role of remote monitoring to prevent exposure to the virus. This study compared remote monitoring of implantable cardioverter defibrillators (ICDs) in patients whose in-person annual visit was substituted for a remote monitoring session with patients who were already scheduled for a remote monitoring session.

Methods: This was a cross-sectional observational study of 329 consecutive patients between 20 March and 24 April 2020. Group 1 included 131 patients whose in-person annual visit was substituted for a remote monitoring session. Group 2 included 198 patients who underwent a remote monitoring session as scheduled in their usual device follow-up. The time interval since the last in-person visit was 13.3 ± 3.2 months in group 1 and 5.9 ± 1.7 months in group 2 (P < .01).

Results: In group 1, 15 patients (11.5%) experienced a clinical event compared to 15 patients (7.6%) in group 2 (P = .25). Nineteen patients (14.5%) required a physician intervention in group 1 compared to 19 patients (9.6%) in group 2 (P = .22). Two patients (1.5%) in group 1 and four patients (2.0%) in group 2 required an early in-person follow-up visit during the pandemic (P > .99).

Conclusion: Remote monitoring of ICDs is useful to identify clinical events and allows physicians to treat patients appropriately during the COVID-19 pandemic regardless of the time interval since their last in-person visit. It reduces significantly in-person visit for regular follow-up.
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http://dx.doi.org/10.1111/pace.14086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675613PMC
November 2020

Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) Study.

Can J Cardiol 2020 Aug 28;36(8):1269-1277. Epub 2020 May 28.

Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Background: Current guidelines recommend 4 weeks of private driving restriction after implantation of a primary-prevention implantable cardioverter-defibrillator (ICD). These driving restrictions result in significant inconvenience and social implications. Advances in medical treatment and ICD programming have lowered the overall rate of device therapies. The objective of this study was to assess the incidence of ICD therapies at 30, 60, and 180 days after implantation.

Methods: Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) was a retrospective cohort study conducted at 2 Canadian university centres enrolling patients with new implantation of a primary-prevention ICD. Device programming was standardised according to current guidelines. A total of 803 patients were enrolled.

Results: The cumulative rates of appropriate ICD therapies at 30, 60, and 180 days were 0.12%, 0.50%, and 0.75%, respectively. There was no syncope during the first 6 months. The median duration to the first appropriate ICD therapy was 208 (range 23-1109) days after implantation. The rate of inappropriate ICD therapies at 30 days was only 0.2%. Overall, < 13.6% of all appropriate ICD therapies occurred within the first 6 months after implantation.

Conclusions: The rate of appropriate ICD therapies within the first 30 days after device insertion is extremely low in contemporary primary prevention cohorts with guideline-concordant device programming. There was no increased risk for ventricular arrhythmia early after ICD insertion. The results of DREAM-ICD suggest the need for a revision of the existing driving restrictions for primary-prevention ICD recipients.
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http://dx.doi.org/10.1016/j.cjca.2020.05.029DOI Listing
August 2020

A Novel Wearable Device for Continuous Ambulatory ECG Recording: Proof of Concept and Assessment of Signal Quality.

Biosensors (Basel) 2019 Jan 21;9(1). Epub 2019 Jan 21.

Electrophysiology Division, Institut Universitaire de cardiologie et de pneumologie de Québec, Québec, G1V 4G5, QC, Canada.

Diagnosis of arrhythmic disorders is challenging because of their short-lasting, intermittent character. Conventional technologies of noninvasive ambulatory rhythm monitoring are limited by modest sensitivity. We present a novel form of wearable electrocardiogram (ECG) sensors providing an alternative tool for long-term rhythm monitoring with the potential of increased sensitivity to detect intermittent or subclinical arrhythmia. The objective was to assess the signal quality and R-R coverage of a wearable ECG sensor system compared to a standard 3-lead Holter. In this phase-1 trial, healthy individuals underwent 24-h simultaneous rhythm monitoring using the OMsignal system together with a 3-lead Holter recording. The OMsignal system consists of a garment (bra or shirt) with integrated sensors recording a single-lead ECG and an acquisition module for data storage and processing. Head-to-head signal quality was assessed regarding adequate P-QRS-T distinction and was performed by three electrophysiologists blinded to the recording technology. The accuracy of signal coverage was assessed using Bland-Altman analysis. Fifteen individuals underwent simultaneous 24-h recording. Signal quality and accuracy of the OMgaments was equivalent to Holter-monitoring (84% vs 93% electrophysiologists rating, = 0.06). Signal coverage of R-R intervals showed a very close overlay between the OMsignal system and Holter signals, mean difference in heart rate of 2 5 bpm. The noise level of OMgarments was comparable to Holter recording. OMgarments provide high signal quality for adequate rhythm analysis, representing a promising novel technology for long-term non-invasive ECG monitoring.
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http://dx.doi.org/10.3390/bios9010017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6468449PMC
January 2019

Validation of a novel single lead ambulatory ECG monitor - Cardiostat™ - Compared to a standard ECG Holter monitoring.

J Electrocardiol 2019 Mar - Apr;53:57-63. Epub 2018 Dec 19.

IUCPQ - Institut Universitaire de Cardiologie et de Pneumologie de Québec, Canada.

Background: Cardiostat™ is a single lead ambulatory ECG monitor. Recording is made through 2 electrodes positioned in a lead 1-like configuration. We first validated its accuracy for atrial fibrillation detection compared to a 12-lead ECG. In the second phase of the study, arrhythmia detection accuracy was compared between Cardiostat™ ambulatory ECG and a standard 24 h Holter ECG monitoring.

Method/results: Phase one of the study included patients undergoing cardioversion for atrial fibrillation (AF) or atrial flutter. Cardiostat™ tracings were compared with standard 12-lead ECG. In the second phase, patients undergoing 24 h ambulatory Holter ECG monitoring for control or suspicion of atrial fibrillation (AF) were included. Simultaneous Holter monitoring and Cardiostat™ ECG recordings were performed. Tracings were analysed and compared. Two hundred twelve monitoring were compared. AF was diagnosed in 73 patients. Agreement between Cardiostat™ ECG and standard Holter monitoring was 99% for AF detection with kappa = 0.99. Kappa correlation for atrial flutter detection was only moderate at 0.51. AF burden was similar in both recordings. Noise hindered analysis in a greater proportion with Cardiostat™ compared to Holter ambulatory ECG (8.5 vs 3.8%).

Conclusion: Cardiostat™ ambulatory ECG device showed excellent correlation with the standard Holter ECG monitoring for AF detection. Holter monitoring was however superior to discriminate premature atrial and ventricular beats and to qualify the morphology of PVCs since it has more vectors for analysis. Added value of Cardiostat™ includes longer monitoring duration, less cumbersome installation and water resistance.
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http://dx.doi.org/10.1016/j.jelectrocard.2018.12.011DOI Listing
July 2020

Cardiac Implantable Electronic Device Infection: Detailed Analysis of Cost Implications.

Can J Cardiol 2018 08 7;34(8):1026-1032. Epub 2018 May 7.

Electrophysiology Division, Institut Universitaire de cardiologie et de pneumologie de Québec, Québec, Canada. Electronic address:

Background: Infections of cardiac implantable electronic devices (CIED) are associated with significant morbidity and mortality. Despite many preventive measures, this condition is associated with significant costs for the health care system.

Methods: We retrospectively analyzed all infection cases referred for lead extraction at a single university hospital over 1 year (2015-2016). We then calculated all costs related to the infection episode per patient using hospital databases and charts review.

Results: Thirty-eight patients with CIED infections (29% women-mean age 71 ± 14 years) were referred for lead extraction (27 pocket infections, 11 endocarditis). Devices were mainly pacemakers (60%). When the pathogen was identified, Staphylococcus aureus methicillin sensitive was the main cause. Extraction was performed in all but 3 cases (92%). One death occurred in the nonextracted group. Respective durations of hospitalization and intravenous and antibiotic administration for patients undergoing extraction were 21 and 36 days. The calculated mean total cost for CIED infection management was CAD$29,907 (median: 26,879; range: CAD$4,827-$62,585). Mean hospital charges were CAD$12,291, accounting for 41% of the total costs.

Conclusions: This study represents the first analysis of the direct costs associated with lead extraction in Canada. Device infections are associated with significant costs and increased morbidity. Any preventive measure will have a significant impact on the economic burden of the health care system and patient outcome after lead extraction.
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http://dx.doi.org/10.1016/j.cjca.2018.05.001DOI Listing
August 2018

Clinical performance of different DF-4 implantable cardioverter defibrillator leads.

Pacing Clin Electrophysiol 2018 Jun 1. Epub 2018 Jun 1.

Department of Cardiology, Institut universitaire de cardiologie et pneumologie de Québec, Quebec, QC, Canada.

Introduction: Implantable cardioverter-defibrillator (ICD) DF-4 connectors have been introduced to facilitate defibrillator lead connection and to reduce the size of device header. There are limited data regarding the overall performance of those leads and no comparison between different ICD DF-4 leads.

Methods: This is a cohort study of consecutive patients implanted with ICD DF-4 lead system at one University Centre between October 2010 and February 2015. A historical control group of patients with ICD DF-1 lead implantation was used for comparison. The following ICD DF-4 leads were evaluated: St. Jude Medical Durata 7122Q (St. Jude Medical, St. Paul, MN, USA), Medtronic Sprint Quattro Secure 6935 M (Medtronic Inc., Minneapolis, MN, USA), Boston Scientific Endotak Reliance 4-Site 0293 (Boston Scientific, Marlborough, MA, USA), and Boston Scientific Reliance 4-Front 0693. This study evaluated the acute and mid-term performances of those leads as well as complications.

Results: A total of 812 patients (age 63 ± 12 years, 80% male, left ventricular ejection fraction 31 ± 12%) underwent implantation of an ICD DF-4 lead. Acute and follow-up R-wave sensing and threshold were excellent. Compared to implantation, intrinsic R waves were higher at follow-up for Boston Scientific and Medtronic leads, and pacing lead impedances were lower for all leads at first follow-up (P < 0.001). The number of lead dislodgement or failure was similar between all leads. The estimated lead survival rates at 3 years were 95.6% for Boston Scientific Endotak 4-Site, 97.1% for Boston Scientific 4-Front, 97.7% for Medtronic Sprint Quattro, and 97.5% for St. Jude Durata (P  =  0.553).

Conclusion: All ICD DF-4 leads had excellent acute and mid-term electrical performances. Longer follow-up will be necessary to confirm their sustained performance.
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http://dx.doi.org/10.1111/pace.13400DOI Listing
June 2018

Feasibility of extravascular pacing with a novel substernal electrode configuration: The Substernal Pacing Acute Clinical Evaluation study.

Heart Rhythm 2018 04 2;15(4):536-542. Epub 2017 Dec 2.

Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada.

Background: Subcutaneous implantable cardioverter-defibrillators provide an alternative to transvenous defibrillation but require higher shock outputs and offer no antitachycardia pacing. The Substernal Pacing Acute Clinical Evaluation (SPACE) study evaluated the feasibility of pacing from an extravascular substernal location.

Objectives: The primary purpose of the SPACE study was to characterize pacing from the substernal space. Secondary objectives included evaluating extracardiac stimulation and recording electrograms.

Methods: The SPACE study prospectively evaluated the feasibility of pacing with a commercially available electrophysiology catheter acutely implanted in the substernal space via minimally invasive subxiphoid access. Pacing data were collected in ≥7 vectors using constant current stimulation up to 20 mA and pulse width up to 10 ms.

Results: Catheter placement was successful in all 26 patients who underwent the procedure, with a mean placement time of 11.7 ± 10.1 minutes. Eighteen patients (69%) had successful ventricular capture in ≥1 tested vector. The mean pacing threshold at a pulse width of 10 ms was 7.3 ± 4.2 mA across all vectors (5.8 ± 4.4 V). Failed capture was generally associated with suboptimal catheter placement or presumed air ingression. A low level of extracardiac stimulation was observed in 1 patient. The mean R-wave amplitude ranged from 2.98 to 4.11 mV in the unipolar configuration and from 0.83 to 3.95 mV in the bipolar configuration.

Conclusion: The data from the SPACE study demonstrate that pacing is feasible from the extravascular substernal location. A substernal electrode configuration has the potential to provide pacing in a future extravascular device without need for intracardiac hardware placement.
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http://dx.doi.org/10.1016/j.hrthm.2017.11.030DOI Listing
April 2018

Canadian Cardiovascular Society/Canadian Heart Rhythm Society 2016 Implantable Cardioverter-Defibrillator Guidelines.

Can J Cardiol 2017 02 6;33(2):174-188. Epub 2016 Oct 6.

Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada.

Sudden cardiac death is a major public health issue in Canada. However, despite the overwhelming evidence to support the use of implantable cardioverter defibrillators (ICDs) in the prevention of cardiac death there remains significant variability in implantation rates across Canada. Since the most recent Canadian Cardiovascular Society position statement on ICD use in Canada in 2005, there has been a plethora of new scientific information to assist physicians in their discussions with patients considered for ICD implantation to prevent sudden cardiac death due to ventricular arrhythmias. We have reviewed, critically appraised, and synthesized the pertinent evidence to develop recommendations regarding: (1) ICD implantation in the primary and secondary prevention of sudden cardiac death in patients with and without ischemic heart disease; (2) when it is reasonable to withhold ICD implantation on the basis of comorbidities; (3) ICD implantation in patients listed for heart transplantation; (4) implantation of a single- vs dual-chamber ICD; (5) implantation of single- vs dual-coil ICD leads; (6) the role of subcutaneous ICDs; and (7) ICD implantation infection prevention strategies. We expect that this document, in combination with the companion article that addresses the implementation of these guidelines, will assist all medical professionals with the care of patients who have had or at risk of sudden cardiac death.
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http://dx.doi.org/10.1016/j.cjca.2016.09.009DOI Listing
February 2017

Extra-anatomic Course of a Right Ventricular Pacing Lead: Clinical Implications.

Can J Cardiol 2016 06 17;32(6):830.e5-6. Epub 2015 Jul 17.

Electrophysiology Division, Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Québec City, Québec, Canada.

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http://dx.doi.org/10.1016/j.cjca.2015.06.036DOI Listing
June 2016

Left ventricular three-dimensional quadripolar lead acute clinical study: the LILAC study.

Pacing Clin Electrophysiol 2015 Apr 28;38(4):438-47. Epub 2015 Jan 28.

Electrophysiology Division, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Canada.

Aims: This multicenter acute clinical study was designed to verify novel three-dimensional (3D) quadripolar lead designs that can achieve ≤2.5 V average pacing capture threshold (PCT) not only at the apex, but also at the base of the left ventricle with phrenic nerve stimulation (PNS) avoidance for cardiac resynchronization.

Methods: During the implant procedure, up to two different left ventricular investigational leads were introduced and tested in the same target coronary vein based on the coronary sinus venogram in a wedged and unwedged position. Adverse events were collected in 30 days following the procedure.

Results: Eighty-seven leads were tested in 50 patients. When the best performing spiral electrode was chosen from each lead testing, the average of the best PCT on spiral in a wedged position was similar to the unwedged position (1.7 ± 1.5 V vs 1.9 ± 1.5 V, P = ns) and was similar to the wedged tip electrode average PCT (1.7 ± 1.5 V vs 1.6 ± 1.6 V, P = ns). In the majority of patients (89-96%), pacing was achievable in a mid-basal ventricular location without PNS.

Conclusions: This acute study demonstrated that a 3D quadripolar spiral lead design can achieve acceptable PCTs and avoid PNS without repositioning the lead at implant in the vast majority of patients. It also demonstrated that this lead design can achieve mid-basal ventricular stimulation with low PCT and good acute stability.
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http://dx.doi.org/10.1111/pace.12584DOI Listing
April 2015

Longitudinal follow-up of Riata leads reveals high annual incidence of new conductor externalization and electrical failure.

J Interv Card Electrophysiol 2014 Dec 16;41(3):217-22. Epub 2014 Nov 16.

Institut universitaire de cardiologie et pneumologie de Québec (IUCPQ), Division of electrophysiology, 2725, chemin Sainte-Foy, Quebec, QC, G1V 4G5, Canada,

Background And Purpose: Riata(TM) defibrillation leads are susceptible to conductor externalization. The point prevalence of insulation defect in Riata(TM) leads is up to 33 %, but prospective data concerning incidence of new lead abnormalities are lacking. The purpose of our study was to determine the annual incidence of new conductor externalizations and electrical lead failure.

Methods: A prospective observational study was conducted at a single tertiary center. One hundred forty-one patients were followed over 12 months. A posterior-anterior (PA)/lateral chest x-ray (CXR) with zooming was performed at baseline and at 12 months to screen for conductor externalization. Electrical abnormalities and clinical outcome were also assessed.

Results: The overall incidence of new insulation defects was 8.5 % at 12 months. High-risk leads for new conductor externalization were lead models 1580, 1582, and 1590 with an annual rate of 11.9, 11.1, and 10 %, respectively. New conductor externalizations were three times more common in 8 Fr leads compared to 7 Fr leads. The overall incidence of new electrical dysfunction was 6.4 % at 12 months. Electrical dysfunction was significantly higher in abnormal leads (25 % [3/12], 4.7 % [6/129]; p = 0.03) and mostly driven by high ventricular pacing thresholds. There was no difference in inappropriate shock or failure of high-voltage therapy.

Conclusion: The annual incidence of new insulation defects in Riata(TM) leads is much higher than previously reported. Lead models 1580, 1582, and 1590 are at highest risk for new conductor externalization. Electrical dysfunction in Riata(TM) leads is also much higher than reported and is associated with conductor externalization.
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http://dx.doi.org/10.1007/s10840-014-9951-6DOI Listing
December 2014

PA/Lateral chest X-ray is equivalent to cine-fluoroscopy for the detection of conductor externalization in defibrillation leads.

Pacing Clin Electrophysiol 2015 Jan 16;38(1):77-83. Epub 2014 Sep 16.

Division of Electrophysiology, Institut universitaire de cardiologie et pneumologie de Québec (IUCPQ), Québec, Canada.

Background: Riata™ and Riata ST defibrillation leads (St. Jude Medical, Sylmar, CA, USA) are susceptible to insulation defects with conductor externalization. Cine-fluoroscopy is considered to be the gold standard for the documentation of insulation defects, but similar detection rates have been reported for posterior-anterior (PA)/lateral chest x-ray (CXR) with zooming.

Objective: Prospective single-center study to assess the diagnostic equivalence of a PA/lateral CXR with zooming for the detection of Riata insulation defects in a direct comparison to cine-fluoroscopy.

Methods: Seventy-eight consecutive patients underwent 3-view cine-fluoroscopy and a PA/lateral CXR. All CXRs and cine-fluoroscopy images were reviewed by blinded electrophysiologists and staff radiologists.

Results: Forty-four of 78 patients had an abnormal cine-fluoroscopy (56%). The diagnostic correlation between PA/lateral CXR and cine-fluoroscopy was excellent (κ = 0.90; 95% confidence interval 0.80-1.00). PA/lateral CXR was equivalent to cine-fluoroscopy for the detection of conductor externalization showing a sensitivity of 97.7% and a specificity of 91.2%. The mean radiation effective dose of CXR was significantly lower compared to cine-fluoroscopy (0.09 millisievert [mSV] vs 0.85 ± 0.47 mSv; P < 0.001). Also, CXR was significantly less expensive.

Conclusion: PA/lateral CXR with zooming is equivalent to cine-fluoroscopy for the detection of Riata insulation defects and should be considered as the preferred screening method.
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http://dx.doi.org/10.1111/pace.12504DOI Listing
January 2015

A multicenter study of shock pathways for subcutaneous implantable defibrillators.

J Cardiovasc Electrophysiol 2014 Jan 9;25(1):29-35. Epub 2013 Oct 9.

Department of Medicine-Cardiology, University Medical Centre, Mannheim, Germany.

Introduction: A purely subcutaneous implantable cardioverter defibrillator (ICD) requires higher energy but may be an effective alternative to transvenous ICDs to deliver lifesaving therapies.

Objective: To identify combinations of anteroposterior subcutaneous shock pathways and waveforms with defibrillation efficacy comparable to transvenous ICDs.

Methods: Defibrillation testing was performed in 141 patients temporarily implanted with an active can emulator and subcutaneous coil electrodes. The patients were subdivided into 5 groups within 2 study phases. In all groups, a posterior electrode was positioned with its tip close to the spine. In the first study phase, 2 different can locations were evaluated: (1) an inframammary pocket (IM-1-750), or (2) a conventional infraclavicular pocket (IC-1-750). In both cases, a 70 J biphasic shock was used (peak voltage 750 V; 270 μF capacitance). In the second phase, configuration IC-1-750 was enhanced by the addition of a second (parasternal) subcutaneous electrode (IC-2-750). Furthermore, the effects of a different 70 J shock waveform (1,000 V, 160 μF) were evaluated for configurations IM-1-750 and IC-2-750 (becoming IM-1-1000 and IC-2-1000).

Results: The proportion of patients satisfying a defibrillation safety margin test of 2 consecutive successes at ≤50 J was 74%, 11%, and 44%, respectively, for the IM-1-750, IC-1-750, and IC-2-750 configurations, and 93% and 86% for the IM-1-1000 and IC-2-1000 configurations.

Conclusions: Defibrillation efficacy comparable to that of a transvenous system was achieved with an anteroposterior subcutaneous ICD configuration, with 160 μF capacitance, 1,000 V, and 70 J output. An infraclavicular pocket location becomes feasible if a parasternal subcutaneous coil is added.
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http://dx.doi.org/10.1111/jce.12281DOI Listing
January 2014

Selective left ventricular sensing lead implantation to overcome undersensing of ventricular fibrillation during implantable cardioverter defibrillator implantation.

Can J Cardiol 2013 Jun 6;29(6):751.e3-6. Epub 2013 Feb 6.

Division of Electrophysiology, Quebec Heart and Lung Institute, Sainte-Foy, Québec, Canada.

Accurate sensing of malignant arrhythmia is critical for the appropriate delivery of therapy from implantable cardioverter defibrillators, and undersensing of ventricular tachyarrhythmias can have catastrophic consequences. Here, we present an unusual case of ventricular fibrillation undersensing from the right ventricular lead at multiple different implantation sites because of very low amplitude voltage signals during induced ventricular fibrillation. A left ventricular sensing electrode was implanted to allow correct sensing and therapy delivery.
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http://dx.doi.org/10.1016/j.cjca.2012.10.027DOI Listing
June 2013

Detection of high incidence of Riata lead breaches by systematic postero-anterior and lateral chest X-ray in a large cohort.

Europace 2013 Mar 1;15(3):402-8. Epub 2012 Nov 1.

Division of Electrophysiology, Quebec Heart and Lung Institute, Affiliated to Laval University, 2725, Chemin Sainte-Foy, Quebec G1V 4G5, Canada.

Aims: Insulation breaches with externalization of conductor cables have been described for St-Jude Medical Riata™ defibrillation leads. Published data on the incidence of Riata lead abnormalities are quite heterogeneous. The objective of this study was to estimate systematically the prevalence of lead abnormalities using a postero-anterior (PA) and lateral chest X-ray (CXR).

Methods And Results: From 2002 to 2008, 552 Riata defibrillation leads were implanted at our centre. We evaluated patients for potential insulation breaches. A PA and lateral CXR was obtained. Chest X-rays were reviewed by two electrophysiologists using a zooming function with magnification up to factor 7.5 and were classified as normal or abnormal for the presence of conductor externalization. A total of 284 patients were included. Riata lead models were 1570, 1580, 1582, 1590, 1592, 7000, 7002, and 7022. The total frequency of radiological lead defects was 24.3%. Insulation breaches occurred at zones of major lead curvature. Mean maximal spacing between extruding lead components was 3.6 ± 1.9 mm (range 2.0-12.4). Abnormal CXRs were more frequent in 8F leads (31.4% vs. 6.3%; P < 0.001). Most defects occurred with lead models 1582 (41.2%) and 1580 (31.4%). Mean time since implantation was longer in abnormal leads (6.7 vs. 5.9 years; P < 0.001). Abnormal leads had higher pacing thresholds (1.1 ± 0.8 V vs. 0.9 ± 0.4 V; P = 0.02).

Conclusion: The incidence of insulation breach in Riata leads is much higher than quoted by the manufacturer or reported by most of the literature. A PA and lateral CXR with zooming appears adequate to identify lead breaches when reviewed by an electrophysiologist. Riata lead breaches without electrical abnormalities present a management dilemma and will require further studies.
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http://dx.doi.org/10.1093/europace/eus339DOI Listing
March 2013

Usefulness of fluorine-18 positron emission tomography/computed tomography for identification of cardiovascular implantable electronic device infections.

J Am Coll Cardiol 2012 May;59(18):1616-25

Department of Medicine, Division of Cardiology, Institut universitaire de cardiologie et pneumologie de Québec, 2725 chemin Sainte-Foy, Québec City, Quebec, Canada.

Objectives: This study evaluated the usefulness of fluorodesoxyglucose marked by fluorine-18 ((18)F-FDG) positron emission tomography (PET) and computed tomography (CT) in patients with suspected cardiovascular implantable electronic device (CIED) infection.

Background: CIED infection is sometimes challenging to diagnose. Because extraction is associated with significant morbidity/mortality, new imaging modalities to confirm the infection and its dissemination would be of clinical value.

Methods: Three groups were compared. In Group A, 42 patients with suspected CIED infection underwent (18)F-FDG PET/CT. Positive PET/CT was defined as abnormal uptake along cardiac devices. Group B included 12 patients without infection who underwent PET/CT 4 to 8 weeks post-implant. Group C included 12 patients implanted for >6 months without infection who underwent PET/CT for another indication. Semi-quantitative ratio (SQR) was obtained from the ratio between maximal uptake and lung parenchyma uptake.

Results: In Group A, 32 of 42 patients with suspected CIED infection had positive PET/CT. Twenty-four patients with positive PET/CT underwent extraction with excellent correlation. In 7 patients with positive PET/CT, 6 were treated as superficial infection with clinical resolution. One patient with positive PET/CT but negative leukocyte scan was considered false positive due to Dacron pouch. Ten patients with negative-PET/CT were treated with antibiotics and none has relapsed at 12.9 ± 1.9 months. In Group B, patients had mild uptake seen at the level of the connector. There was no abnormal uptake in Group C patients. Median SQR was significantly higher in Group A (A = 2.02 vs. B = 1.08 vs. C = 0.57; p < 0.001).

Conclusions: PET/CT is useful in differentiating between CIED infection and recent post-implant changes. It may guide appropriate therapy.
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http://dx.doi.org/10.1016/j.jacc.2011.11.059DOI Listing
May 2012

Prospective comparison between conventional transseptal puncture and transseptal needle puncture with radiofrequency energy.

J Interv Card Electrophysiol 2011 Sep 19;31(3):237-42. Epub 2011 Apr 19.

Institut Universitaire de Cardiologie et Pneumologie de Québec, Quebec, QC, Canada.

Purpose: Patients undergoing left atrial ablation require transseptal puncture, which can be challenging, even for experienced physicians. This study compared the efficacy and safety of radiofrequency (RF) energy transseptal punctures to conventional approach.

Methods: Patients requiring transseptal puncture for left atrial access were included using either conventional approach or the NRG™ RF transseptal needle as first attempt. Procedure time for transseptal access, fluoroscopy time, crossover, and safety of both techniques were compared.

Results: A total of 241 transseptal punctures were performed in 148 consecutive patients (114 men, 54 ± 10 years, left atrial volume 32 ± 10 ml/m(2)) who underwent 157 procedures with left atrial access, mainly for atrial fibrillation. It was a repeat transseptal procedure in 49 patients. Procedures were guided by transesophageal echocardiography. RF transseptal puncture was planned in 119 procedures. RF was delivered in 98 procedures (82%) for 139/187 punctures: 48 punctures did not require RF, including 25 punctures performed by exposing the needle tip, 22 through patent foramen ovale, and 1 RF delivery failure by the generator. Average time for RF transseptal was 4.8 ± 2.8 min compared to 7.5 ± 8.5 min for conventional approach (p = 0.045). Fluoroscopy time was 1.8 ± 1.3 min for RF transseptal and 2.9 ± 2.8 min for standard approach (p = 0.043). Four patients required crossover to RF transseptal needle in the conventional group (p = 0.003). One tamponade occurred at the end of procedure in a patient using the RF needle, and one interatrial septum dissection with aortic root hematoma occurred in the conventional group.

Conclusions: Transseptal needle puncture using RF energy can be performed safely and quickly under imaging guidance.
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http://dx.doi.org/10.1007/s10840-011-9564-2DOI Listing
September 2011

Cardiac arrest as a major complication of bilateral cervico-dorsal sympathectomy.

Interact Cardiovasc Thorac Surg 2009 Feb 27;8(2):238-9. Epub 2008 Nov 27.

Department of Cardiology, Institut universitaire de cardiologie et de pneumologie, Hôpital Laval, Québec, Canada.

Severe palmar and/or axillary hyperhidrosis can be socially and psychologically very disturbing. We present a case of a patient who suffered from a 43 s asystolic cardiac arrest the night following a second contralateral thoracoscopic T(2)-T(3) sympathectomy for severe axillary and truncal hyperhidrosis. The cardiovascular effects of cervico-dorsal sympathectomy will be reviewed. Evaluation required to prevent such a serious cardiac complication will also be discussed.
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http://dx.doi.org/10.1510/icvts.2008.188011DOI Listing
February 2009

The Brugada syndrome in Canada: a unique French-Canadian experience.

Can J Cardiol 2007 Oct;23 Suppl B:71B-75B

Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval Hospital, Sainte-Foy, Quebec.

Unlabelled: The Brugada syndrome (BS) is a clinical entity involving cardiac sodium channelopathy, typical electrocardiogram (ECG) changes and predisposition to ventricular arrhythmia. This syndrome is mainly recognized by specialized cardiologists and electrophysiologists. Data regarding BS largely come from multicentre registries or Asian countries. The present report describes the Quebec Heart Institute experience, including the clinical characteristics and prognosis of native French-Canadian subjects with the Brugada-type ECG pattern.

Methods And Results: BS has been diagnosed in 35 patients (mean age 51 +/- 12 years) at the Quebec Heart Institute since 2001. Patients were referred from primary care physicians for ECG abnormalities, syncope or ventricular arrhythmia, or were diagnosed incidentally on an ECG obtained for other purposes. The abnormal ECG was recognized after a syncopal spell in four patients and during family screening in four patients. All of the others were incidental findings following a routine ECG. No patient had a family history of sudden cardiac death at younger than 45 years of age. In this population, right bundle branch block pattern with more than 2 mm ST segment elevation in leads V1 to V3 was recorded spontaneously in 25 patients and was induced by sodium blockers in 10 patients. The sodium channel blocker test was performed in 21 patients and was positive in 18 patients (86%). An electrophysiological study was performed in 20 of 35 patients, during which ventricular fibrillation was induced in five patients; three of the five patients were previously asymptomatic. An implantable cardioverter-defibrillator was implanted in six of 35 patients (17%), including three of four patients with a history of syncope. A loop recorder was implanted in three patients. After a mean follow-up of 36 +/- 18 months, one patient died from a noncardiac cause and one patient (with a history of syncope) received an appropriate shock from his implantable cardioverter-defibrillator. No event occurred in the asymptomatic population.

Conclusions: BS is present in the French-Canadian population and is probably under-recognized. Long-term prognosis of individuals with BS, especially in sporadic, asymptomatic cases, needs to be clarified.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2794469PMC
http://dx.doi.org/10.1016/s0828-282x(07)71014-0DOI Listing
October 2007

Catheter ablation for cardiac arrhythmias: a 14-year experience with 5330 consecutive patients at the Quebec Heart Institute, Laval Hospital.

Can J Cardiol 2007 Oct;23 Suppl B:67B-70B

Institut Universitaire de Cardiologie et de Pneumologie, Hopital Laval, Sainte-Foy, Quebec.

Background: Catheter ablation is a curative treatment with excellent success and minimal complication rates for patients with supraventricular or ventricular arrhythmias.

Methods: The acute outcomes and complications of all catheter ablation procedures for supraventricular and ventricular arrhythmias performed at the Quebec Heart Institute (Sainte-Foy, Quebec) during a 14-year period from January 1, 1993, to December 31, 2006, were prospectively assessed. The ablation procedures were classified according to the arrhythmias induced using standard electrophysiological techniques and definitions. Immediate success and complication rates were prospectively included in the database.

Results: A total of 5330 patients had catheter ablation performed at the Institute during the period assessed. The mean (+/- SD) age of patients was 50 +/- 18 years (range four to 97 years), and 2340 patients (44%) were men. Most of the patients were younger than 75 years (group 1), and 487 (9%) were 75 years of age and older (group 2). Indications for ablations were as follows: atrioventricular nodal re-entry tachycardia (AVNRT) in 2263 patients, accessory pathways in 1147 patients, atrioventricular node ablation in 803 patients, typical atrial flutter in 377 patients and atrial tachycardia in 160 patients; 580 patients had other ablation procedures. The overall success rates were 81% for atrial tachycardia, 92% for accessory pathways or flutter, and 99% for AVNRT or atrioventricular node ablation. There was no difference in the success rates of the younger (group 1) and older (group 2) patients. Seventy-seven patients (1.4%) had complications, including 11 major events (myocardial infarction in one patient, pulmonary embolism in three patients and permanent pacemaker in seven patients). In patients undergoing AVNRT ablation, two had a permanent pacemaker implanted immediately after the procedure and three had a permanent pacemaker implanted at follow-up.

Conclusions: The results confirm that radiofrequency ablation is safe and effective, supporting ablation therapy as a first-line therapy for the majority of patients with cardiac arrhythmias.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2794475PMC
http://dx.doi.org/10.1016/s0828-282x(07)71013-9DOI Listing
October 2007

Reduced incidence of vagally induced atrial fibrillation and expression levels of connexins by n-3 polyunsaturated fatty acids in dogs.

J Am Coll Cardiol 2007 Oct 24;50(15):1505-12. Epub 2007 Sep 24.

Institut Universitaire de Cardiologie et Pneumologie, Quebec, Canada.

Objectives: This open-label canine study assessed whether n-3 polyunsaturated fatty acids (PUFAs) prevent vagally induced atrial fibrillation (AF) and influence atrial tissue expression levels of connexins (CXs).

Background: n-3 polyunsaturated fatty acids in fish oils protect against sudden cardiac death and reduce postoperative AF. Changes in spatial organization of gap junctions or cellular CX levels have been linked to arrhythmogenesis.

Methods: Vagally induced AF was studied. Eight dogs were given fish oil daily for 14 days. Eight control dogs had reproducibly induced AF and were re-evaluated after intravenous administration of fish oil. Atrial fibrillation was compared, and n-3 PUFA, CX40, and CX43 protein levels were assessed in atrial biopsies.

Results: Atrial tissue n-3 PUFA levels increased in oral treatment dogs (5.78 +/- 0.71% vs. 2.49 +/- 0.46% in control animals, p < 0.001). No difference was observed for atrial refractory periods or hemodynamic or electrocardiographic parameters. Incidence of AF in oral treatment dogs decreased 79% with the extra stimulus technique (10.5% vs. 48.9%, p = 0.003) and 42% with burst induction (22.5% vs. 38.8%, p = 0.038). Both CX40 and CX43 levels were lower in oral treatment dogs (60% [p = 0.019] and 42% [p = 0.038] lower, respectively); protection against AF was mostly related to reduced CX40 expression levels (p = 0.02). In dogs that were given intravenous n-3 PUFAs, AF inducibility by the extra stimulus technique was reduced from 75.0% to 28.6% (p = 0.002).

Conclusions: Oral treatment with fish oils increased atrial n-3 PUFA levels and reduced vulnerability to induction of AF in this dog model. Modulation of cardiac CX by n-3 PUFAs probably contributes to the antiarrhythmic effects of fish oils.
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http://dx.doi.org/10.1016/j.jacc.2007.05.046DOI Listing
October 2007

Usefulness of transesophageal echocardiography in the isolation of pulmonary veins in the treatment of atrial fibrillation.

Pacing Clin Electrophysiol 2007 Jan;30 Suppl 1:S116-9

Institut Universitaire de cardiologie et pneumologie de l'Université Laval, Laval Hospital, Quebec City, Quebec, Canada.

Background: New imaging strategies for atrial fibrillation (AF) ablation should enhance the safety of this technique. The role of transesophageal echocardiography (TEE) in this setting has not been prospectively evaluated.

Methods: Under general anesthesia, 85 patients underwent TEE-guided AF ablation. A hybrid technique was performed with circular pulmonary veins (PV) lesions and antrum and ostial electrical isolation guided by TEE. TEE excluded left atrial (LA) thrombus, guided transseptal puncture and catheter positioning, and helped to identify PV ostia and their velocities. The TEE probe localized the esophagus, its temperature (T degrees ) and micro bubbles formation.

Results: Overall, one patient had a LA clot. The esophagus was located close to left PV in 38%, the right PV in 28%, midline in 17% and with an oblique course in 17% of patients. Right and left superior PV velocities were detected in 100%, left inferior PV in 88% and right inferior PV in 82% of patients. Microbubbles were detected in 9 patients (11%). Elevation of TEE T degrees occurred in 14 patients (16%) and was regularly observed when lesions were applied over the TEE probe shadow, in close proximity to the posterior wall. Two major complications (1 tamponade, 1 PV laceration) occurred and were detected early by TEE.

Conclusions: TEE offers advantages compared to a map-guided only approach. It is a reliable tool to assess esophagus T degrees and localization, guide transseptal puncture, delineate the PV ostia, and monitor complications.
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http://dx.doi.org/10.1111/j.1540-8159.2007.00619.xDOI Listing
January 2007