Publications by authors named "Frederic Sacher"

439 Publications

The RV-V transition ratio: A novel electrocardiographic criterion for the differentiation of right versus left outflow tract premature ventricular complexes.

Heart Rhythm O2 2021 Oct 2;2(5):521-528. Epub 2021 Aug 2.

Onassis Cardiac Surgery Centre, Athens, Greece.

Background: Several electrocardiographic (ECG) indices have been proposed to predict the origin of premature ventricular complexes (PVCs) with precordial transition in lead V. However, the accuracy of these algorithms is limited.

Objectives: We sought to evaluate a new ECG criterion differentiating the origin of outflow tract with precordial transition in lead V.

Methods: We included in our study patients exhibiting outflow tract PVCs with precordial transition in lead V referred for ablation. We analyzed a novel new ECG criterion, RV-V transition ratio, for distinguishing right from left idiopathic outflow tract PVCs with precordial transition in lead V. The RV-V transition ratio was defined as (RV1+RV2+RV3) / (RV1+RV2+RV3) SR (sinus rhythm).

Results: We included 58 patients in our study. The ratio was lower for right ventricular outflow tract origins than left ventricular outflow tract (LVOT) origins (median [interquartile range], 0.6953 [0.4818-1.0724] vs 1.5219 [1.1582-2.4313], < .001). Receiver operating characteristic analysis revealed an area under the curve of 0.856 for the ratio, and a cut-off value of ≥0.9 predicting LVOT origin with 94% sensitivity and 73% specificity. This ratio was superior to any previously proposed ECG criterion for differentiating right from left outflow tract PVCs.

Conclusion: The RV-V transition ratio is a simple and accurate novel ECG criterion for distinguishing right from left idiopathic outflow tract PVCs with precordial transition in lead V.
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http://dx.doi.org/10.1016/j.hroo.2021.07.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8505196PMC
October 2021

Right ventricular outflow tract electroanatomical abnormalities in asymptomatic and high-risk symptomatic patients with Brugada syndrome: Evidence for a new risk stratification tool?

J Cardiovasc Electrophysiol 2021 Oct 1. Epub 2021 Oct 1.

Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France.

Introduction: Microstructural abnormalities at the epicardium of the right ventricular outflow tract (RVOT) may provide the arrhythmia substrate in Brugada syndrome (BrS). Endocardial unipolar electroanatomical mapping allows the identification of epicardial abnormalities. We evaluated the clinical implications of an abnormal endocardial substrate as perceived by high-density electroanatomical mapping (HDEAM) in patients with BrS.

Methods: Fourteen high-risk BrS patients with aborted sudden cardiac death (SCD) (12 males, mean age: 41.9 ± 11.8 years) underwent combined endocardial-epicardial HDEAM of the right ventricle/RVOT, while 40 asymptomatic patients (33 males, mean age: 42 ± 10.7 years) underwent endocardial HDEAM. Based on combined endocardial-epicardial procedures, endocardial HDEAM was considered abnormal in the presence of low voltage areas (LVAs) more than 1 cm with bipolar signals less than 1 mV and unipolar signals less than 5.3 mV. Programmed ventricular stimulation (PVS) was performed in all patients.

Results: The endocardial unipolar LVAs were colocalized with epicardial bipolar LVAs (p = .0027). Patients with aborted SCD exhibited significantly wider endocardial unipolar (p < .01) and bipolar LVAs (p < .01) compared with asymptomatic individuals. A substrate size of unipolar LVAs more than 14.5 cm (area under the curve [AUC]: 0.92, p < .001] and bipolar LVAs more than 3.68 cm (AUC: 0.82, p = .001) distinguished symptomatic from asymptomatic patients. Patients with ventricular fibrillation inducibility (23/54) demonstrated broader endocardial unipolar (p < .001) and bipolar LVAs (p < .001) than noninducible patients. The presence of unipolar LVAs more than 13.5 cm (AUC: 0.95, p < .001) and bipolar LVAs more than 2.97 cm (AUC: 0.78, p < .001) predicted a positive PVS.

Conclusion: Extensive endocardial electroanatomical abnormalities identify high-risk patients with BrS. Endocardial HDEAM may allow risk stratification of asymptomatic patients referred for PVS.
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http://dx.doi.org/10.1111/jce.15262DOI Listing
October 2021

Effect of electrode size and spacing on electrograms: Optimal electrode configuration for near-field electrogram characterization.

Heart Rhythm 2021 Sep 14. Epub 2021 Sep 14.

CHU Bordeaux, IHU LIRYC, Université de Bordeaux, Bordeaux, France.

Background: Detailed effects of electrode size on electrograms (EGMs) have not been systematically examined.

Objectives: We aimed to elucidate the effect of electrode size on EGMs and investigate an optimal configuration of electrode size and interelectrode spacing for gap detection and far-field reduction.

Methods: This study included 8 sheep in which probes with different electrode size and interelectrode spacing were epicardially placed on healthy, fatty, and lesion tissues for measurements. In study 1, EGMs were compared between 3 electrode sizes (0.1 mm/0.2 mm/0.5 mm) with 3 mm spacing. In study 2, gap to lesion voltage ratio and healthy to fat tissue voltage ratio were evaluated, as indices of capability in gap detection and far-field reduction, in different electrode sizes (0.1 mm/0.2 mm/0.5 mm) and interelectrode spacing (0.1 mm/0.2 mm/0.3 mm/0.5 mm/3 mm) and the optimal electrode size and interelectrode spacing were determined. In study 3, bipolar EGMs in atrial fibrillation (AF) were compared between PentaRay and the optimal probe determined in study 2.

Results: Study 1 demonstrated that unipolar voltage and the duration of EGMs increased as the electrode size increased in any tissue (P < .001). Bipolar EGMs had the same tendency in healthy/fatty tissues, but not in lesions. Study 2 showed that significantly higher gap to lesion volume ratio and healthy to fat tissue voltage ratio were provided by a smaller electrode (0.2 mm or 0.3 mm electrode) and smaller spacing (0.1 mm spacing), but 0.3 mm electrode/0.1 mm spacing provided a larger bipolar voltage (P < .05). Study 3 demonstrated that 0.3 mm electrode/0.1 mm spacing provided less deflection with more discrete EGMs (P < .0001) with longer and more reproducible AF cycle length (P < .0001) compared to PentaRay.

Conclusion: Electrode size affects both unipolar and bipolar EGMs. Catheters with microelectrodes and very small interelectrode spacing may be superior in gap detection and far-field reduction. Importantly, this electrode configuration could dramatically reduce artifactual complex fractionated atrial electrograms and may open a new era for AF mapping.
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http://dx.doi.org/10.1016/j.hrthm.2021.09.011DOI Listing
September 2021

The prevalence of left and right bundle branch block morphology ventricular tachycardia amongst patients with arrhythmogenic cardiomyopathy and sustained ventricular tachycardia: insights from the European Survey on Arrhythmogenic Cardiomyopathy.

Europace 2021 Sep 7. Epub 2021 Sep 7.

Second Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Kateřinská 1660/32, 121 08 Nové Město, Prague, Czech Republic.

Aims: In arrhythmogenic cardiomyopathy (ACM), sustained ventricular tachycardia (VT) typically displays a left bundle branch block (LBBB) morphology while a right bundle branch block (RBBB) morphology is rare. The present study assesses the VT morphology in ACM patients with sustained VT and their clinical and genetic characteristics.

Methods And Results: Twenty-six centres from 11 European countries provided information on 954 ACM patients who had ≥1 episode of sustained VT spontaneously documented during patients' clinical course. Arrhythmogenic cardiomyopathy was defined according to the 2010 Task Force Criteria, and VT morphology according to the QRS pattern in V1. Overall, 882 (92.5%) patients displayed LBBB-VT alone and 72 (7.5%) RBBB-VT [alone in 42 (4.4%) or in combination with LBBB-VT in 30 (3.1%)]. Male sex prevalence was 79.3%, 88.1%, and 56.7% in the LBBB-VT, RBBB-VT, and LBBB + RBBB-VT groups, respectively (P = 0.007). First RBBB-VT occurred 5 years after the first LBBB-VT (46.5 ± 14.4 vs 41.1 ± 15.8 years, P = 0.011). An implanted cardioverter-defibrillator was more frequently implanted in the RBBB-VT (92.9%) and the LBBB + RBBB-VT groups (90%) than in the LBBB-VT group (68.1%) (P < 0.001). Mutations in PKP2 predominated in the LBBB-VT (65.2%) and the LBBB + RBBB-VT (41.7%) groups while DSP mutations predominated in the RBBB-VT group (45.5%). By multivariable analysis, female sex was associated with LBBB + RBBB-VT (P = 0.011) while DSP mutations were associated with RBBB-VT (P < 0.001). After a median follow-up of 103 (51-185) months, death occurred in 106 (11.1%) patients with no intergroup difference (P = 0.176).

Conclusion: RBBB-VT accounts for a significant proportion of sustained VTs in ACM. Sex and type of pathogenic mutations were associated with VT type, female sex with LBBB + RBBB-VT, and DSP mutation with RBBB-VT.
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http://dx.doi.org/10.1093/europace/euab190DOI Listing
September 2021

Purkinje triggers of ventricular fibrillation in patients with hypertrophic cardiomyopathy.

J Cardiovasc Electrophysiol 2021 Aug 27. Epub 2021 Aug 27.

Hôpital Cardiologique du Haut Lévêque, Centre Hospitalier Universitaire de Bordeaux, Bordeaux-Pessac, France.

Introduction: Ventricular fibrillation (VF) is the main mechanism of sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM). The origin of VF and the success of catheter ablation to eliminate recurrent episodes in this population are poorly understood.

Methods And Results: From 2010 to 2014, five patients with HCM (age 21 ± 9 years, three female) underwent invasive electrophysiological studies and ablation at our center after resuscitation from recurrent (9 ± 7) episodes of VF. Ventricular premature beats (VPBs), seen to initiate VF in certain cases, were recorded noninvasively before the ablation procedure. Postprocedural computed tomography (CT) was performed to correlate ablation sites with myocardial hypertrophy in three patients. Outcomes were assessed by clinical follow-up and implantable cardioverter-defibrillator interrogations. VPB triggers were localized invasively to the distal left Purkinje conduction system (left posterior fascicle [2], left anterior fascicle [1], and both fascicles [2]). All targeted VF triggers were successfully eliminated by radiofrequency ablation in the left ventricle. Among patients with postablation CT imaging, 93 ± 12% of ablation sites corresponded to hypertrophied segments. Over 50 ± 38 months, four of five patients were free from primary VF without antiarrhythmic drug therapy. One patient who had 13 episodes of VF before ablation had a single recurrence.

Conclusion: In our study of patients with HCM and recurrent VF, VF was not initiated from the myocardium but rather from Purkinje arborization. These sources colocalized with the hypertrophic substrate, suggesting electromechanical interaction. Focal ablation at these sites was associated with a marked reduction in VF burden.
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http://dx.doi.org/10.1111/jce.15231DOI Listing
August 2021

Outcomes after catheter ablation of ventricular tachycardia without implantable cardioverter-defibrillator in selected patients with arrhythmogenic right ventricular cardiomyopathy.

Europace 2021 09;23(9):1428-1436

Cardiology Division, Toulouse Rangueil University Hospital, INSERM U1048, Toulouse, France.

Aims: The roles of implantable cardioverter-defibrillators (ICDs) and radiofrequency catheter ablation (RCA) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) and well-tolerated monomorphic ventricular tachycardia (MVT) are debated. In this multicentre retrospective study, we aimed at reporting the outcome of selected patients with ARVC after RCA without a back-up ICD.

Methods And Results: Patients with ARVC who underwent RCA of well-tolerated MVT at 10 tertiary centres across 5 countries, without an ICD before and 3 months after RCA, without syncope or electrical storm, and with left ventricular ejection fraction ≥50% were included. In total, 65 ARVC patients [mean age 44.5 ± 13.2 years, 78% males] underwent RCA of MVT between 2003 and 2016. Clinical presentation was palpitations in 51 (80%) patients. One (2%) patient had >1 clinical MVT. At the ablative procedure, clinical MVTs (mean rate 185 ± 32 b.p.m.) were inducible in 50 (81%) patients. Epicardial ablation was performed in 19 (29%) patients. Complete acute success was achieved in 47 (72%) patients. After a median follow-up of 52.4 months (range 12.3-171.4), there was no death or aborted cardiac arrest, and VT recurred in 19 (29%) patients. Survival without VT recurrence was estimated at 88%, 80%, and 68%, 12, 36, and 60 months after RCA, respectively, and was significantly associated with the approach and the procedural outcome.

Conclusion: In patients with ARVC, well-tolerated MVT without a back-up ICD did not lead to fatal arrhythmic event after RCA despite VT recurrences in some. Our data suggest that RCA may be an alternative to ICD in selected ARVC patients.
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http://dx.doi.org/10.1093/europace/euab172DOI Listing
September 2021

Characteristics of macroreentrant atrial tachycardias using an anatomical bypass: Pseudo-focal atrial tachycardia case series.

J Cardiovasc Electrophysiol 2021 09 8;32(9):2451-2461. Epub 2021 Aug 8.

Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France.

Introduction: Human atria comprise distinct layers. One layer can bypass another, and lead to a downstream centrifugal propagation at their interface. We sought to characterize anatomical substrates, electrophysiological properties, and ablation outcomes of "pseudo-focal" atrial tachycardias (ATs), defined as macroreentrant ATs mimicking focal ATs.

Methods And Results: We retrospectively analyzed left atrial ATs showing centrifugal propagation with postpacing intervals (PPIs) after entrainment pacing suggestive of a macroreentrant mechanism. A total of 22 patients had pseudo-focal ATs consisting of 15 perimitral and 7 roof-dependent flutters. A low-voltage area was consistently found at the collision site and colocalized with distinct anatomical structures like the: (1) coronary sinus-great cardiac vein bundle (27%), (2) vein of Marshall bundle (18%), (3) Bachmann bundle (27%), (4) septopulmonary bundle (18%), and (5) fossa ovalis (9%). The mean missing tachycardia cycle length (TCL) was 65 ± 31 ms (22%) on the endocardial activation map. PPI was 0 [0-15] ms and 0 [0-21] ms longer than TCL at the breakthrough site and the opposite site, respectively. While feasible in 21 pseudo-focal ATs (95%), termination was better achieved by blocking the anatomical isthmus than ablating the breakthrough site [20/21 (95%) vs. 1/5 (20%); p < .001].

Conclusion: Perimitral and roof-dependent flutters with centrifugal propagation are favored by a low-voltage area located at well-identified anatomical structures. Comprehensive entrainment pacing maneuvers are crucial to distinguish pseudo-focal ATs from true focal ATs. Blocking the anatomical isthmus is a better therapeutic option than ablating the breakthrough site.
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http://dx.doi.org/10.1111/jce.15186DOI Listing
September 2021

Vein of Marshall Ethanol Infusion: Feasibility, Pitfalls, and Complications in Over 700 Patients.

Circ Arrhythm Electrophysiol 2021 Aug 19;14(8):e010001. Epub 2021 Jul 19.

Department of Cardiac Pacing and Electrophysiology, IHU Liryc, Electrophysiology and Heart Modeling Institute, University of Bordeaux, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France (T.K., N.D., J.D., A.D., T.N., T.T., F.D.R., C.A., P.K., Y.N., R.T., R.C., G.C., H.C., F.S., M. Hocini, P.J., M. Haïssaguerre, T.P.).

[Figure: see text].
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http://dx.doi.org/10.1161/CIRCEP.121.010001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8376276PMC
August 2021

Sex differences in the origin of Purkinje ectopy-initiated idiopathic ventricular fibrillation.

Heart Rhythm 2021 Oct 11;18(10):1647-1654. Epub 2021 Jul 11.

IHU Liryc, Electrophysiology and Heart Modeling Institute, Foundation Bordeaux Université, Bordeaux, France; Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.

Background: Purkinje ectopics (PurkEs) are major triggers of idiopathic ventricular fibrillation (VF). Identifying clinical factors associated with specific PurkE characteristics could yield insights into the mechanisms of Purkinje-mediated arrhythmogenicity.

Objective: The purpose of this study was to examine the associations of clinical, environmental, and genetic factors with PurkE origin in patients with PurkE-initiated idiopathic VF.

Methods: Consecutive patients with PurkE-initiated idiopathic VF from 4 arrhythmia referral centers were included. We evaluated demographic characteristics, medical history, clinical circumstances associated with index VF events, and electrophysiological characteristics of PurkEs. An electrophysiology study was performed in most patients to confirm the Purkinje origin.

Results: Eighty-three patients were included (mean age 38 ± 14 years; 44 [53%] women), of whom 32 had a history of syncope. Forty-four patients had VF at rest. PurkEs originated from the right ventricle (RV) in 41 patients (49%), from the left ventricle (LV) in 36 (44%), and from both ventricles in 6 (7%). Seasonal and circadian distributions of VF episodes were similar according to PurkE origin. The clinical characteristics of patients with RV vs LV PurkE origins were similar, except for sex. RV PurkEs were more frequent in men than in women (76% vs 24%), whereas LV and biventricular PurkEs were more frequent in women (81% vs 19% and 83% vs 17%, respectively) (P < .0001).

Conclusion: PurkEs triggering idiopathic VF originate dominantly from the RV in men and from the LV or both ventricles in women, adding to other sex-related arrhythmias such as Brugada syndrome or long QT syndrome. Sex-based factors influencing Purkinje arrhythmogenicity warrant investigation.
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http://dx.doi.org/10.1016/j.hrthm.2021.07.007DOI Listing
October 2021

Pulsed field ablation prevents chronic atrial fibrotic changes and restrictive mechanics after catheter ablation for atrial fibrillation.

Europace 2021 Jul 8. Epub 2021 Jul 8.

Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France.

Aims: Pulsed field ablation (PFA), a non-thermal ablative modality, may show different effects on the myocardial tissue compared to thermal ablation. Thus, this study aimed to compare the left atrial (LA) structural and mechanical characteristics after PFA vs. thermal ablation.

Methods And Results: Cardiac magnetic resonance was performed pre-ablation, acutely (<3 h), and 3 months post-ablation in 41 patients with paroxysmal atrial fibrillation (AF) undergoing pulmonary vein (PV) isolation with PFA (n = 18) or thermal ablation (n = 23, 16 radiofrequency ablations, 7 cryoablations). Late gadolinium enhancement (LGE), T2-weighted, and cine images were analysed. In the acute stage, LGE volume was 60% larger after PFA vs. thermal ablation (P < 0.001), and oedema on T2 imaging was 20% smaller (P = 0.002). Tissue changes were more homogeneous after PFA than after thermal ablation, with no sign of microvascular damage or intramural haemorrhage. In the chronic stage, the majority of acute LGE had disappeared after PFA, whereas most LGE persisted after thermal ablation. The maximum strain on PV antra, the LA expansion index, and LA active emptying fraction declined acutely after both PFA and thermal ablation but recovered at the chronic stage only with PFA.

Conclusion: Pulsed field ablation induces large acute LGE without microvascular damage or intramural haemorrhage. Most LGE lesions disappear in the chronic stage, suggesting a specific reparative process involving less chronic fibrosis. This process may contribute to a preserved tissue compliance and LA reservoir and booster pump functions.
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http://dx.doi.org/10.1093/europace/euab155DOI Listing
July 2021

Accuracy of automatic abnormal potential annotation for substrate identification in scar-related ventricular tachycardia.

J Cardiovasc Electrophysiol 2021 08 9;32(8):2216-2224. Epub 2021 Jul 9.

Department of Cardiac Pacing and Electrophysiology, IHU Liryc, Electrophysiology and Heart Modeling Institute, University Hospital (CHU), University of Bordeaux, Bordeaux, France.

Introduction: Ultrahigh-density mapping for ventricular tachycardia (VT) is increasingly used. However, manual annotation of local abnormal ventricular activities (LAVAs) is challenging in this setting. Therefore, we assessed the accuracy of the automatic annotation of LAVAs with the Lumipoint algorithm of the Rhythmia system (Boston Scientific).

Methods And Results: One hundred consecutive patients undergoing catheter ablation of scar-related VT were studied. Areas with LAVAs and ablation sites were manually annotated during the procedure and compared with automatically annotated areas using the Lumipoint features for detecting late potentials (LP), fragmented potentials (FP), and double potentials (DP). The accuracy of each automatic annotation feature was assessed by re-evaluating local potentials within automatically annotated areas. Automatically annotated areas matched with manually annotated areas in 64 cases (64%), identified an area with LAVAs missed during manual annotation in 15 cases (15%), and did not highlight areas identified with manual annotation in 18 cases (18%). Automatic FP annotation accurately detected LAVAs regardless of the cardiac rhythm or scar location; automatic LP annotation accurately detected LAVAs in sinus rhythm, but was affected by the scar location during ventricular pacing; automatic DP annotation was not affected by the mapping rhythm, but its accuracy was suboptimal when the scar was located on the right ventricle or epicardium.

Conclusion: The Lumipoint algorithm was as/more accurate than manual annotation in 79% of patients. FP annotation detected LAVAs most accurately regardless of mapping rhythm and scar location. The accuracy of LP and DP annotations varied depending on mapping rhythm or scar location.
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http://dx.doi.org/10.1111/jce.15148DOI Listing
August 2021

Epicardial course of the musculature related to the great cardiac vein: Anatomical considerations and clinical implications for mitral isthmus block after vein of Marshall ethanol infusion.

Heart Rhythm 2021 Jul 1. Epub 2021 Jul 1.

Unité d'Électrophysiologie Cardiaque, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC), University of Bordeaux, Bordeaux, France.

Background: Mitral isthmus gaps have been ascribed to an epicardial musculature anatomically related to the great cardiac vein (GCV) and the vein of Marshall (VOM). Their lumen offers an access for radiofrequency application or ethanol infusion, respectively.

Objective: The purpose of this study was to evaluate the frequency of mitral isthmus gaps accessible via the GCV lumen, to assess their location around the GCV circumference, and to propose an efficient ablation strategy when present.

Methods: One hundred consecutive patients underwent VOM ethanol infusion (step 1) and endocardial linear ablation from the mitral annulus to the left inferior pulmonary vein (step 2). In cases of mitral isthmus gap, endovascular ablation of the GCV anchored wall facing the left atrium was systematically performed (step 3), while the opposite GCV free wall was targeted in case of block failure only (step 4).

Results: After VOM ethanol infusion and endocardial ablation, mitral isthmus block occurred in 51 patients (51%). Pacing maneuvers and activation sequences demonstrated an epicardial gap via the VOM in 2 patients (2%) and via the GCV in 47 patients (47%). In the latter case, block was achieved at the GCV anchored wall in 42 patients (89%) and the GCV free wall in 5 patients (11%). Global success rate of mitral isthmus block was 98%. No tamponade occurred.

Conclusion: With the advent of VOM ethanol infusion, residual mitral isthmus gaps are mostly eliminated within the first centimeter of the GCV. Thorough mapping of the entire circumference of the GCV wall can help identify these epicardial gaps.
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http://dx.doi.org/10.1016/j.hrthm.2021.06.1202DOI Listing
July 2021

Role of endocardial ablation in eliminating an epicardial arrhythmogenic substrate in patients with Brugada syndrome.

Heart Rhythm 2021 Oct 26;18(10):1673-1681. Epub 2021 Jun 26.

Department of Cardiac Pacing and Electrophysiology, IHU Liryc, Electrophysiology and Heart Modeling Institute, University of Bordeaux, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France. Electronic address:

Background: Epicardial ablation is occasionally limited by coronary artery (CA) injuries or epicardial fat (EF).

Objective: The purpose of this study was to evaluate the anatomic obstacles that prevent ablation of epicardial abnormal potentials (EAPs) in patients with Brugada syndrome (BrS) and to investigate the feasibility of EAP elimination by endocardial right ventricular (RV) ablation.

Methods: This study included 16 BrS patients with previous ventricular fibrillation (VF), including 10 with an electrical storm. Data from multidetector computed tomography were assessed, and the proximity of the CA and EF was correlated with EAPs.

Results: EAPs were present in the epicardial RV outflow tract and RV inferior wall in all patients and 12 patients (75%), respectively. These EAPs were present within 5 mm of the main body and branches of the right CA in 14 patients (87.5%). However, only 1.4% ± 2.9% of the EAP area was covered with thick EF (≥8 mm). Partial EAP elimination by endocardial RV ablation was feasible in all 10 patients, with 53.3% successful endocardial RV radiofrequency applications for eliminating EAPs. After the procedure, VF remained inducible in 37.5% of the patients. During the 25.1 ± 29.1 months of follow-up, no patients experienced an electrical storm, and VF burden significantly decreased (median VF episodes before and after ablation: 7 and 0, respectively).

Conclusion: EAPs are near the CA in most BrS patients, thereby requiring caution during epicardial ablation, whereas EF is less of an issue. Endocardial ablation is feasible to eliminate some EAPs and may be combined with epicardial ablation.
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http://dx.doi.org/10.1016/j.hrthm.2021.06.1188DOI Listing
October 2021

Mechanism of premature ventricular complexes in a patient with ischemic cardiomyopathy.

J Cardiovasc Electrophysiol 2021 07 1;32(7):1982-1984. Epub 2021 Jun 1.

INSERM, Center de Recherche Cardio-Thoracique de Bordeaux, Université BORDEAUX, Bordeaux, France.

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http://dx.doi.org/10.1111/jce.15120DOI Listing
July 2021

Pulsed field ablation selectively spares the oesophagus during pulmonary vein isolation for atrial fibrillation.

Europace 2021 09;23(9):1391-1399

IHU LIRYC-CHU Bordeaux, Univ. Bordeaux, Inserm U1045, Avenue du Haut Lévêque, 33604 Pessac, France.

Aims: Extra-atrial injury can cause complications after catheter ablation for atrial fibrillation (AF). Pulsed field ablation (PFA) has generated preclinical data suggesting that it selectively targets the myocardium. We sought to characterize extra-atrial injuries after pulmonary vein isolation (PVI) between PFA and thermal ablation methods.

Methods And Results: Cardiac magnetic resonance (CMR) imaging was performed before, acutely (<3 h) and 3 months post-ablation in 41 paroxysmal AF patients undergoing PVI with PFA (N = 18, Farapulse) or thermal methods (N = 23, 16 radiofrequency, 7 cryoballoon). Oesophageal and aortic injuries were assessed by using late gadolinium-enhanced (LGE) imaging. Phrenic nerve injuries were assessed from diaphragmatic motion on intra-procedural fluoroscopy. Baseline CMR showed no abnormality on the oesophagus or aorta. During ablation procedures, no patient showed phrenic palsy. Acutely, thermal methods induced high rates of oesophageal lesions (43%), all observed in patients showing direct contact between the oesophagus and the ablation sites. In contrast, oesophageal lesions were observed in no patient ablated with PFA (0%, P < 0.001 vs. thermal methods), despite similar rates of direct contact between the oesophagus and the ablation sites (P = 0.41). Acute lesions were detected on CMR on the descending aorta in 10/23 (43%) after thermal ablation, and in 6/18 (33%) after PFA (P = 0.52). CMR at 3 months showed a complete resolution of oesophageal and aortic LGE in all patients. No patient showed clinical complications.

Conclusion: PFA does not induce any signs of oesophageal injury on CMR after PVI. Due to its tissue selectivity, PFA may improve safety for catheter ablation of AF.
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http://dx.doi.org/10.1093/europace/euab090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8427383PMC
September 2021

Impact of Pulmonary Valve Replacement on Ventricular Arrhythmias in Patients With Tetralogy of Fallot and Implantable Cardioverter-Defibrillator.

JACC Clin Electrophysiol 2021 Oct 28;7(10):1285-1293. Epub 2021 Apr 28.

Auxerre Hospital, Auxerre, France.

Objectives: This study aimed to assess the impact of pulmonary valve replacement (PVR) on ventricular arrhythmias burden in a population of tetralogy of Fallot (TOF) patients with continuous cardiac monitoring by implantable cardioverter-defibrillators (ICDs).

Background: Sudden cardiac death is a major cause of death in TOF, and right ventricular overload is commonly considered to be a potential trigger for ventricular arrhythmias.

Methods: Data were analyzed from a nationwide French ongoing study (DAI-T4F) including all TOF patients with an ICD since 2000. Survival data with recurrent events were used to compare the burden of appropriate ICD therapies before and after PVR in patients who underwent PVR over the study period.

Results: A total of 165 patients (mean age 42.2 ± 13.3 years, 70.1% male) were included from 40 centers. Over a median follow-up period of 6.8 (interquartile range: 2.5 to 11.4) years, 26 patients (15.8%) underwent PVR. Among those patients, 18 (69.2%) experienced at least 1 appropriate ICD therapy. When considering all ICD therapies delivered before (n = 62) and after (n = 16) PVR, the burden of appropriate ICD therapies was significantly lower after PVR (HR: 0.21; 95% confidence interval [CI]: 0.08 to 0.56; p = 0.002). Respective appropriate ICD therapies rates per 100 person-years were 44.0 (95% CI: 35.7 to 52.5) before and 13.2 (95% CI: 7.7 to 20.5) after PVR (p < 0.001). In the overall cohort, PVR before ICD implantation was also independently associated with a lower risk of appropriate ICD therapy in primary prevention patients (HR: 0.29 [95% CI: 0.10 to 0.89]; p = 0.031).

Conclusions: In this cohort of high-risk TOF patients implanted with an ICD, the burden of appropriate ICD therapies was significantly reduced after PVR. While optimal indications and timing for PVR are debated, these findings suggest the importance of considering ventricular arrhythmias in the overall decision-making process. (French National Registry of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator [DAI-T4F]; NCT03837574).
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http://dx.doi.org/10.1016/j.jacep.2021.02.022DOI Listing
October 2021

Local abnormal ventricular activity detection in scar-related VT: Microelectrode versus conventional bipolar electrode.

Pacing Clin Electrophysiol 2021 Jun 12;44(6):1075-1084. Epub 2021 May 12.

Department of Cardiac Pacing and Electrophysiology, Univ. Bordeaux, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France.

Background: Conventional bipolar electrodes (CBE) may be suboptimal to detect local abnormal ventricular activities (LAVAs). Microelectrodes (ME) may improve the detection of LAVAs. This study sought to elucidate the detectability of LAVAs using ME compared with CBE in patients with scar-related ventricular tachycardia (VT).

Methods: We included consecutive patients with structural heart disease who underwent radiofrequency catheter ablation for scar-related VT using either of the following catheters equipped with ME: QDOTTM or IntellaTip MIFITM. Detection field of LAVA potentials were classified as three types: Type 1 (both CBE and ME detected LAVA), Type 2 (CBE did not detect LAVA while ME did), and Type 3 (CBE detected LAVA while ME did not).

Results: In 16 patients (68 ± 16 years; 14 males), 260 LAVAs electrograms (QDOT = 72; MIFI = 188) were analyzed. Type 1, type 2, and type 3 detections were 70.8% (QDOT, 69.4%; MIFI, 71.3%), 20.0% (QDOT, 23.6%; MIFI, 18.6%) and 9.2% (QDOT, 6.9%; MIFI, 10.1%), respectively. The LAVAs amplitudes detected by ME were higher than those detected by CBE in both catheters (QDOT: ME 0.79 ± 0.50 mV vs. CBE 0.41 ± 0.42 mV, p = .001; MIFI: ME 0.73 ± 0.64 mV vs. CBE 0.38 ± 0.36 mV, p < .001).

Conclusions: ME allow to identify 20% of LAVAs missed by CBE. ME showed higher amplitude LAVAs than CBE. However, 9.2% of LAVAs can still be missed by ME.
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http://dx.doi.org/10.1111/pace.14253DOI Listing
June 2021

Varying physiologic ventricular resynchronization with changes in atrial rhythm in a patient with a right-sided accessory pathway and right bundle branch block.

J Electrocardiol 2021 May-Jun;66:122-124. Epub 2021 Apr 21.

Department of Cardiac Pacing and Electrophysiology, IHU Liryc, Electrophysiology and Heart Modeling Institute, Univ. Bordeaux, Bordeaux University Hospital (CHU), 33600 Pessac- Bordeaux, France.

We describe varying physiologic ventricular resynchronization owing to differences in atrial rhythm in a patient with the right-sided accessory pathway and pre-existing right bundle branch block.
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http://dx.doi.org/10.1016/j.jelectrocard.2021.04.012DOI Listing
July 2021

Persistent atrial fibrillation ablation in cardiac laminopathy: Electrophysiological findings and clinical outcomes.

Heart Rhythm 2021 Jul 31;18(7):1115-1121. Epub 2021 Mar 31.

Unité d'électrophysiologie, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux-Pessac, France. Electronic address:

Background: Little is known about persistent atrial fibrillation (AF) ablation in patients with cardiac laminopathy (CLMNA).

Objectives: We aimed to characterize atrial electrophysiological properties and to assess the long-term outcomes of persistent AF ablation in patients with CLMNA.

Methods: All patients with CLMNA referred in our center for persistent AF ablation were retrospectively included. Left atrial (LA) volume, left atrial appendage (LAA) cycle length, interatrial conduction delay, and LA voltage amplitude were analyzed during the ablation procedure. Sinus rhythm maintenance and LA contractile function were assessed during long-term follow-up.

Results: From 2011 to 2020, 8 patients were included. The mean age was 47 ± 14 years, and 3 patients (38%) were women. The LA volume was 205.8 ± 43.7 mL; the LAA AF cycle length was 250.7 ± 85.6 ms; and the interatrial conduction delay was 296.5 ± 110.1 ms. Large low-voltage areas (>50% of the LA surface; <0.5 mV electrogram) were recorded in all 8 patients. Two patients had inadvertent LAA disconnection during ablation. All A waves recorded by pulsed Doppler in sinus rhythm were <30 cm/s before and after AF ablation. Early arrhythmia recurrence was recorded in 7 patients (87%) (time to recurrence 4 ± 4 months; 1.5 procedures per patient). After a mean follow-up of 4.4 ± 3.2 years, 4 patients underwent implantable cardioverter-defibrillator therapy for life-threatening ventricular arrhythmia and 3 patients finally underwent heart transplantation.

Conclusion: Patients with persistent AF afflicted by CLMNA exhibit severe LA impairment because of large low-voltage areas, prolonged conduction velocity, and reduced contractile function. Ablation procedures have a limited effect with a high recurrence rate.
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http://dx.doi.org/10.1016/j.hrthm.2021.03.040DOI Listing
July 2021

Differentiating atrial tachycardias with centrifugal activation: Lessons from high-resolution mapping.

Heart Rhythm 2021 Jul 29;18(7):1122-1131. Epub 2021 Mar 29.

Lyric Institute, CHU Bordeaux, Université de Bordeaux, Bordeaux-Pessac, France.

Background: Centrifugal activation is not always the origin of a focal atrial tachycardia (AT) ("true-focal"), but passive activation from the other structures ("pseudo-focal").

Objective: We aimed to establish a method to differentiate true-focal from pseudo-focal.

Methods: In 49 centrifugal activations in 35 patients with AT, 12-lead electrocardiogram, activation map, atrial global activation histogram (GAH), and local electrograms were analyzed. GAH demonstrates the relation between the activation area and timing through the cycle length, displayed with a normalized value, ranging from 0 (smallest activation area) to 1.0 (largest activation area).

Results: Of 30 centrifugal activations observed in the septal region, 6/30 (20.0%) were true-focal. The remaining 24/60 (80.0%) were pseudo-focal, of which 23 (95.8%) were from the opposite chamber. P-wave/flutter-wave duration < 200 ms discriminated true-focal from pseudo-focal (sensitivity 100%; specificity 54.5%; positive predictive value 33.3%; negative predictive value 100%). Multiple breakthrough ruled out the possibility of a true-focal AT. Other differentiating factors were an activation area within the initial 20 ms of <5 mm and a typical QS pattern electrogram at the origin. Of 19 centrifugal activations observed outside the septal regions, 7 were true-focal and 12 were pseudo-focal exited from an epicardial structure: 10 of 12 (83.3%) were located around the left atrial appendage and ridge. Flutter wave, GAH score ≤ 0.05, and GAH score < 0.1 for >110 ms of cycle length differentiated true-focal from pseudo-focal with a sensitivity/negative predictive value of 100%. GAH score < 0.1 for >40% of the cycle length simply discriminated true-focal from pseudo-focal with 100% accuracy.

Conclusion: Centrifugal activation is not necessarily due to a focal AT but passive activation. The activation map with GAH in addition to the 12-lead electrocardiogram and local electrograms enables an accurate differentiation.
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http://dx.doi.org/10.1016/j.hrthm.2021.03.038DOI Listing
July 2021

Significance of manifest localized staining during ethanol infusion into the vein of Marshall.

Heart Rhythm 2021 Jul 16;18(7):1057-1063. Epub 2021 Mar 16.

Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France.

Background: Localized staining due to venule injury is attributable to ethanol infusion into the vein of Marshall (Et-VOM).

Objective: The purpose of this study was to investigate adverse outcomes of localized staining during Et-VOM in patients undergoing ablation for atrial fibrillation.

Methods: Two hundred four patients (age 64 ± 10 years; 153 male) were sorted based on the aspect of localized staining. Staining of atrial myocardium that spread uniformly along the VOM vascular tree following selective VOM venography was considered normal, in contrast to predominantly localized staining that spread concentrically from a focal point due to vascular injury. Outcomes between the 2 groups were compared.

Results: Localized staining was observed in 27% of patients. No patients developed clinically significant pericardial effusions during Et-VOM; however, 7 patients developed pericardial effusions on the first postprocedural day (3.6% in patients with vs 3.4% in patients without localized staining). No significant difference was found in achievement of acute mitral isthmus (MI) block (96% vs 98%) and size of the endocardial low-voltage area (8.5 ± 4.1 cm vs 9.3 ± 5.3 cm) in patients with and without localized staining, respectively. Long-term follow-up was not impacted by localized staining. Freedom from recurrent atrial tachyarrhythmias (66% vs 76%) and durability of MI block (57% vs 54%) were not significantly different with and without localized staining. There were no cases of rehospitalization for pericarditis, chronic pericardial effusion, or heart failure.

Conclusion: In our study, localized staining was frequent but was not associated with clinically relevant impact or disadvantages.
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http://dx.doi.org/10.1016/j.hrthm.2021.03.023DOI Listing
July 2021

Ligament of Marshall ablation for persistent atrial fibrillation.

Pacing Clin Electrophysiol 2021 May 5;44(5):782-791. Epub 2021 Apr 5.

LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France.

Beyond pulmonary vein isolation, the two main additional strategies: Cox-Maze procedure or targeting of electrical signatures (focal bursts, rotational activities, meandering wavelets), remain controversial. High-density mapping of these arrhythmias has demonstrated firstly that a patchy lesion set is highly proarrhythmogenic, favoring macro-re-entry through conduction slowing and providing pivots for localized re-entry. Secondly, discrete anatomical structures such as the Vein or Ligament of Marshall (VOM/LOM) and the coronary sinus (CS) have epicardial muscular bundles that are more frequently involved in re-entry than previously thought. The Marshall Bundle can be ablated at any point along its course from the mid-to-distal coronary sinus to the left atrial appendage. If necessary, the VOM may be directly ablated using ethanol infusion to eliminate PV contributions and produce conduction block across the mistral isthmus. Ethanol ablation of the VOM, supplemented with RF ablation, may be more effective in producing conduction block at the mitral isthmus than repeat RF ablation alone.
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http://dx.doi.org/10.1111/pace.14208DOI Listing
May 2021

Ante-mortem characterization of sudden deaths as first-manifestation in Italy.

J Interv Card Electrophysiol 2021 Feb 27. Epub 2021 Feb 27.

Electrophysiology Department, LIRYC Institute, Bordeaux University Hospital, Bordeaux, France.

Purpose: There is a relative paucity of data on ante-mortem clinical characteristics of young (age 1 to 35 years) sudden death (SD) victims. The aim of the study was to characterize ante-mortem characteristics of SD victims, in a selected national cohort identified by a web search.

Methods: A dataset of all SD (January 2010 and December 2015) was built from national forensic data and medical records, integrated with Google search model. Families were contacted to obtain consent for interviews. Data were obtained on ante-mortem symptoms. ECG characteristics and autopsy data were available.

Results: Out of 301 SD cases collected, medical and family history was available in 132 (43.9%). Twenty-eight (21.1%) had a positive family history for SD. SD occurred during sport/effort in 76 (57.6%). One hundred twelve (85%) SD cases had no prior reported symptoms. Autopsy data were available in 100/132 (75.8%) cases: an extra cardiac cause was identified in 20 (20%). Among the 61 cases with a cardiac diagnosis, 21 (34%) had hypertrophic cardiomyopathy. Among the 19 (19%) victims without structural abnormalities, molecular autopsy identified pathogenic variants for channelopathies in 9 cases. Ten (10%) victims had no identifiable cause.

Conclusions: Most SD were due to cardiac causes and occurred in previously asymptomatic patients. SD events mainly occurred during strenuous activity. In a minority of cases, no cause was identified. The web-based selection criteria, and incomplete data retrieval, need to be carefully taken into account for data interpretation and reproducibility.
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http://dx.doi.org/10.1007/s10840-021-00949-5DOI Listing
February 2021

Dormant conduction in the right ventricular outflow tract unmasked by adenosine in a patient with Brugada syndrome.

J Cardiovasc Electrophysiol 2021 04 10;32(4):1182-1186. Epub 2021 Mar 10.

Department of Cardiac Pacing and Electrophysiology, IHU Liryc, Electrophysiology and Heart Modeling Institute, Univ. Bordeaux, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France.

Recent data of electrophysiological mapping in patients with Brugada syndrome (BrS) suggest that the presence of an abnormal arrhythmogenic substrate in the epicardial right ventricular outflow tract is responsible for ST-segment elevation and ventricular fibrillation (VF). Complete elimination of the epicardial abnormal potentials normalizes Brugada-pattern electrocardiogram and suppresses VF recurrence. We herein report the first case of BrS in which an injection of adenosine unmasked dormant conduction in the epicardial RVOT after the disappearance of the epicardial potentials.
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http://dx.doi.org/10.1111/jce.14974DOI Listing
April 2021

Use of high-density activation and voltage mapping in combination with entrainment to delineate gap-related atrial tachycardias post atrial fibrillation ablation.

Europace 2021 07;23(7):1052-1062

Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut Lévêque, Avenue de Magellan, 33604 Pessac Cedex, France.

Aims: An incomplete understanding of the mechanism of atrial tachycardia (AT) is a major determinant of ablation failure. We systematically evaluated the mechanisms of AT using ultra-high-resolution mapping in a large cohort of patients.

Methods And Results: We included 107 consecutive patients (mean age: 65.7 ± 9.2 years, males: 81 patients) with documented endocardial gap-related AT after left atrial ablation for persistent atrial fibrillation (AF). We analysed the mechanism of 134 AT (94 macro-re-entries and 40 localized re-entries) using high-resolution activation mapping in combination with high-density voltage and entrainment mapping. Voltage in the conducting channels may be extremely low, even <0.1 mV (0.14 ± 0.095 mV, 51 of 134 AT, 41%), and almost always <0.5 mV (0.03-0.5 mV, 133 of 134 AT, 99.3%). The use of multipolar Orion, HDGrid, and Pentaray catheters improved our accuracy in delineating ultra-low-voltage areas critical for maintenance of the circuit of endocardial gap-related AT. Conventional ablation catheters often do not detect any signal (noise level) even using adequate contact force, and only multipolar catheters of small electrodes and shorter interelectrode space can detect clear fractionated low-amplitude and high frequency signals, critical for re-entry maintenance. We performed a diagnosis in 112 out of 134 AT (83.6%) using only activation mapping and in 134 out of 134 AT (100%) using the combination of activation and entrainment mapping.

Conclusion: High-resolution activation mapping in combination with high-density voltage and entrainment mapping is the ideal strategy to delineate the critical part of the circuit in endocardial gap-related re-entrant AT after AF ablation.
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http://dx.doi.org/10.1093/europace/euaa394DOI Listing
July 2021

Ventricular tachycardia in a patient with repaired d-transposition of the great arteries.

HeartRhythm Case Rep 2021 Jan 17;7(1):26-29. Epub 2020 Oct 17.

Department of Cardiac Electrophysiology, IHU Liryc, Electrophysiology and Heart Modeling Institute, Univ. Bordeaux, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France.

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http://dx.doi.org/10.1016/j.hrcr.2020.10.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813791PMC
January 2021
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