Publications by authors named "Gian-Battista Chierchia"

250 Publications

Segmental nonocclusive cryoballoon ablation of pulmonary veins and extrapulmonary vein structures: Best practices III.

Heart Rhythm 2021 Apr 24. Epub 2021 Apr 24.

Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium.

Although cryoballoon ablation of atrial fibrillation (AF) traditionally has been guided by pulmonary vein (PV) occlusion, there is evidence and growing interest in performing segmental, nonocclusive cryoballoon ablation to target not only large/common PVs but extra-PV structures such as the left atrial (LA) roof and posterior wall in conjunction with PV isolation. A number of studies have demonstrated improved clinical efficacy associated with nonocclusive cryoballoon ablation of the LA roof and posterior wall in addition to PV isolation, particularly in patients with persistent AF. Not only can the cryoballoon be used for targeting extra-PV structures through segmental, nonocclusive ablation, but the large size and durability of cryolesions coupled with the enhanced stability afforded through cryoadhesion render the cryoballoon an effective tool for such an approach. This article reviews the rationale and the practical approach to segmental, nonocclusive cryoballoon ablation of large/common PV antra and the LA roof and posterior wall.
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http://dx.doi.org/10.1016/j.hrthm.2021.04.020DOI Listing
April 2021

On the Dutch Registry of catheter ablation of atrial fibrillation.

Europace 2021 Mar 29. Epub 2021 Mar 29.

University Hospital Brussels, Brussels, Belgium.

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http://dx.doi.org/10.1093/europace/euab067DOI Listing
March 2021

Cryoballoon ablation vs. antiarrhythmic drugs: first-line therapy for patients with paroxysmal atrial fibrillation.

Europace 2021 Mar 17. Epub 2021 Mar 17.

Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Brussels, Belgium.

Aims: Treatment guidelines for patients with atrial fibrillation (AF) suggest that patients should be managed with an antiarrhythmic drug (AAD) before undergoing catheter ablation (CA). This study evaluated whether pulmonary vein isolation employing cryoballoon CA is superior to AAD therapy for the prevention of atrial arrhythmia (AA) recurrence in rhythm control naive patients with paroxysmal AF (PAF).

Methods And Results: A total of 218 treatment naive patients with symptomatic PAF were randomized (1 : 1) to cryoballoon CA (Arctic Front Advance, Medtronic) or AAD (Class I or III) and followed for 12 months. The primary endpoint was ≥1 episode of recurrent AA (AF, atrial flutter, or atrial tachycardia) >30 s after a prespecified 90-day blanking period. Secondary endpoints included the rate of serious adverse events (SAEs) and recurrence of symptomatic palpitations (evaluated via patient diaries). Freedom from AA was achieved in 82.2% of subjects in the cryoballoon arm and 67.6% of subjects in the AAD arm (HR = 0.48, P = 0.01). There were no group differences in the time-to-first (HR = 0.76, P = 0.28) or overall incidence [incidence rate ratio (IRR)=0.79, P = 0.28] of SAEs. The incidence rate of symptomatic palpitations was lower in the cryoballoon (7.61 days/year) compared with the AAD arm (18.96 days/year; IRR = 0.40, P < 0.001).

Conclusions: Cryoballoon CA was superior to AAD therapy, significantly reducing AA recurrence in treatment naive patients with PAF. Additionally, cryoballoon CA was associated with lower symptom recurrence and a similar rate of SAEs compared with AAD therapy.
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http://dx.doi.org/10.1093/europace/euab029DOI Listing
March 2021

A novel noncontact high-resolution charge density mapping system to guide ablation of complex atrial arrhythmias: overview of device technology and application.

Expert Rev Med Devices 2021 Apr 13;18(4):343-350. Epub 2021 Apr 13.

Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium.

: Despite advances in imaging technology to guide ablative therapies, catheter ablation of more complex arrhythmias continues to be a challenge in part due to suboptimal mechanistic understanding of these arrhythmias by conventional mapping systems. A novel noncontact charge density mapping system has been designed to overcome some of these limitations.: Hereby, we present an overview of this novel, charge density-based global chamber mapping approach. We initially highlight the concept of charge density, describe further the device technology and finally summarize the clinical application of this system.: Noncontact charge density mapping provides a more localized, high-resolution global panoramic assessment of cardiac activation. This might contribute to uncover the mechanisms of more complex arrhythmias such as persistent atrial fibrillation or unstable atrial tachycardias with the ultimate goal to guide the ablation therapy.
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http://dx.doi.org/10.1080/17434440.2021.1902302DOI Listing
April 2021

Concomitant thoracoscopic left cardiac sympathectomy and RVOT epicardial ablation of the arrhythmogenic substrate in a patient with Long QT and Brugada syndromes related to uncommon sodium channel beta-subunit mutation.

Pacing Clin Electrophysiol 2021 Mar 9. Epub 2021 Mar 9.

Heart Rhythm Management Centre, Postgraduate program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel,  Brussels, Belgium.

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http://dx.doi.org/10.1111/pace.14215DOI Listing
March 2021

Single procedural outcomes in the setting of percutaneous ablation for persistent atrial fibrillation: a propensity-matched score comparison between different strategies.

J Interv Card Electrophysiol 2021 Feb 24. Epub 2021 Feb 24.

Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Brussels, Belgium.

Background: Catheter ablation for persistent atrial fibrillation (persAF) is associated with less favorable outcomes than for paroxysmal AF. To improve success rates, left atrial (LA) substrate modification is frequently performed in addition to pulmonary vein isolation (PVI). The purpose of the study was to compare 4 different ablation approaches using radiofrequency catheter ablation (RFCA) or cryoballoon ablation (CB-A) for persAF and to evaluate the respective outcomes on a midterm follow-up of 12 months.

Methods: We did a propensity score-matched comparison of 30 patients undergoing PVI + LA posterior wall isolation (LAPWI) with CB-A, 30 patients who underwent PVI + linear ablation (roof and mitral lines) using RFCA, 60 patients with PVI alone using CB-A, and 60 patients who had PVI alone using RFCA. The endpoint was recurrence of documented atrial tachyarrhythmias (ATas) > 30 s at 1-year follow-up.

Results: After 12 months, freedom from ATas after a single procedure was 83.3% in the PVI + LAPWI group, 46.7% in the PVI + linear ablation group, 58.3% in the PVI-alone CB-A group, and 61.6% PVI-alone RFCA (p = 0.03). Moreover, freedom from ATas was significantly higher comparing the PVI + LAPWI group with each of the other groups.

Conclusions: In this propensity-matched comparison of strategies for persAF, LAPW ablation in addition to PVI with CB-A seems to improve 1-year outcome in comparison to PVI + linear ablation using RFCA and to PVI alone using RFCA or CB-A. Randomized comparisons are eagerly awaited.
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http://dx.doi.org/10.1007/s10840-021-00968-2DOI Listing
February 2021

Safety, effectiveness, and quality of life following pulmonary vein isolation with a multi-electrode radiofrequency balloon catheter in paroxysmal atrial fibrillation: 1-year outcomes from SHINE.

Europace 2020 Jan 15. Epub 2020 Jan 15.

Department of Cardiology, Na Homolce Hospital, Roentgenova 37, 150 00 Praha 5, Czechia.

Aims: To evaluate the safety and effectiveness of a compliant multi-electrode radiofrequency balloon catheter (RFB) used with a multi-electrode diagnostic catheter for pulmonary vein isolation (PVI).

Methods And Results: This prospective, multicentre, single-arm study was conducted at six European sites and enrolled patients with symptomatic paroxysmal atrial fibrillation. The primary effectiveness endpoint was entrance block in treated pulmonary veins (PVs) after adenosine/isoproterenol challenge. The primary safety endpoint was the occurrence of primary adverse events (PAEs) within 7 days. Cerebral magnetic resonance imaging and neurological assessments were performed pre- and post-ablation in a subset of patients. Atrial arrhythmia recurrence was assessed over 12 months via transtelephonic and Holter monitoring. Quality of life was assessed by the Atrial Fibrillation Effect on Quality of Life (AFEQT) questionnaire. Of 85 patients undergoing ablation per study protocol, PV entrance block was achieved in all (one PV required touch-up with a focal catheter). Acute reconnection of ≥1 PVs after adenosine/isoproterenol challenge was observed in 9.3% (30/324) of PVs ablated. Post-ablation, silent cerebral lesions were detected in 9.7% (3/31) of patients assessed, all of which was resolved at 1-month follow-up. One patient experienced a PAE (retroperitoneal bleed). Freedom from documented symptomatic and all arrhythmia was 72.2% and 65.8% at 12 months. Four patients (4.7%) underwent repeat ablation. Significant improvements in all AFEQT subscale scores were seen at 6 and 12 months.

Conclusion: PVI with the novel RFB demonstrated favourable safety and effectiveness, with low repeat ablation rate and clinically meaningful improvement in quality of life.

Clinicaltrials.gov Registration Number: NCT03437733.
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http://dx.doi.org/10.1093/europace/euaa382DOI Listing
January 2020

Comparison between superior vena cava ablation in addition to pulmonary vein isolation and standard pulmonary vein isolation in patients with paroxysmal atrial fibrillation with the cryoballoon technique.

J Interv Card Electrophysiol 2021 Jan 15. Epub 2021 Jan 15.

Heart Rhythm Management Center, Postgraduate program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, Brussels, Belgium.

Background: Paroxysmal atrial fibrillation (PAF) can be triggered by non-pulmonary vein foci, like the superior vena cava (SVC). The latter is correlated with improved result in terms of freedom from atrial tachycardias (ATs), when electrical isolation of this vessel utilizing radiofrequency energy (RF) is achieved.

Objectives: Evaluate the clinical impact, in patients with PAF, of the SVC isolation (SVCi) in addition to ordinary pulmonary vein isolation (PVI) by means of the second-generation cryoballoon (CB) METHODS: A total of 100 consecutive patients that underwent CB ablation for PAF were retrospectively selected. Fifty consecutive patients received PVI followed by SVCi by CB application, and the following 50 consecutive patients received standard PVI. All patients were followed 12 months.

Results: The mean time to SVCi was 36.7 ± 29.0 s and temperature at SVC isolation was - 35 (- 18 to - 40) °C. Real-time recording (RTR) during SVCi was observed in 42 (84.0%) patients. At the end of 12 months of follow-up, freedom from ATs was achieved in 36 (72%) patients in the PVI only group and in 45 (90%) patients of the SVC and PV isolation group (Fisher's exact test p = 0.039, binary logistic regression: p = 0.027, OR = 0.28, 95%CI = 0.09-0.86). In survival analysis, SVC and PV isolation group was also associated with improved freedom from ATs (log-rank test: p = 0.017, Cox regression: p = 0.026, HR = 0.31, 95%CI = 0.11-0.87).

Conclusion: Superior vena cava isolation with the CB in addition to PVI might improve freedom from ATs if compared to PVI alone at 1-year follow-up.
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http://dx.doi.org/10.1007/s10840-020-00932-6DOI Listing
January 2021

Substrate mapping of the left atrium in persistent atrial fibrillation: spatial correlation of localized complex conduction patterns in global charge-density maps to low-voltage areas in 3D contact bipolar voltage maps.

J Interv Card Electrophysiol 2021 Jan 8. Epub 2021 Jan 8.

Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, Brussels, Belgium.

Purpose: This study aimed to investigate the spatial relationship between low-voltage areas (LVAs) in bipolar voltage mapping (BVM) and localized complex conduction (LCC)-cores in a global, non-contact, charge-density-based imaging, and mapping system (AcM).

Methods: Patients with history of index PVI for PsAF and scheduled for a repeat ablation procedure for recurrence of the same arrhythmia were enrolled between August 2018 and February 2020. All patients underwent both substrate mappings of the left atrium (LA) with the CARTO 3D map-ping system and with AcM.

Results: Ten patients where included in our analysis. All presented with persistency of PVI in all veins at the moment of repeat procedure. There was no linear relationship in BVM maps between SR and CSd (correlation coefficient 0.31 ± 0.15), SR and CSp (0.36 ± 0.12) and CSd and CSp (0.43 ± 0.10). The % overlap of localized irregular activation (LIA), localized rotational activation (LRA) and Focal (F) regions with LVA was lower at 0.2 mV compared to 0.5 mV (4.97 ± 7.39%, 3.27 ± 5.25%, 1.09 ± 1.92% and 12.59 ± 11.81%, 7.8 ± 9.20%, 4.62 ± 5.27%). Sensitivity and specificity are not significantly different when comparing composite maps with different LVA cut-offs. AURC was 0.46, 0.48, and 0.39 for LIA, LRA, and Focal, respectively.

Conclusion: Due to wave front direction dependency, LVAs mapped with BVM in sinus rhythm and during coronary sinus pacing only partially overlap in patients with PsAF. LCC-cores mapped during PsAF partially co-localize with LVAs.
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http://dx.doi.org/10.1007/s10840-020-00926-4DOI Listing
January 2021

Short P-Wave Duration is a Marker of Higher Rate of Atrial Fibrillation Recurrences after Pulmonary Vein Isolation: New Insights into the Pathophysiological Mechanisms Through Computer Simulations.

J Am Heart Assoc 2021 Jan 7;10(2):e018572. Epub 2021 Jan 7.

Division of Cardiology Cardiocentro Ticino Lugano Switzerland.

Background Short ECG P-wave duration has recently been demonstrated to be associated with higher risk of atrial fibrillation (AF). The aim of this study was to assess the rate of AF recurrence after pulmonary vein isolation in patients with a short P wave, and to mechanistically elucidate the observation by computer modeling. Methods and Results A total of 282 consecutive patients undergoing a first single-pulmonary vein isolation procedure for paroxysmal or persistent AF were included. Computational models studied the effect of adenosine and sodium conductance on action potential duration and P-wave duration (PWD). About 16% of the patients had a PWD of 110 ms or shorter (median PWD 126 ms, interquartile range, 115 ms-138 ms; range, 71 ms-180 ms). At Cox regression, PWD was significantly associated with AF recurrence (=0.012). Patients with a PWD <110 ms (hazard ratio [HR], 2.20; 95% CI, 1.24-3.88; =0.007) and patients with a PWD ≥140 (HR, 1.87, 95% CI, 1.06-3.30; =0.031) had a nearly 2-fold increase in risk with respect to the other group. In the computational model, adenosine yielded a significant reduction of action potential duration 90 (52%) and PWD (7%). An increased sodium conductance (up to 200%) was robustly accompanied by an increase in conduction velocity (26%), a reduction in action potential duration 90 (28%), and PWD (22%). Conclusions One out of 5 patients referred for pulmonary vein isolation has a short PWD which was associated with a higher rate of AF after the index procedure. Computer simulations suggest that shortening of atrial action potential duration leading to a faster atrial conduction may be the cause of this clinical observation.
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http://dx.doi.org/10.1161/JAHA.120.018572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955300PMC
January 2021

Left atrial hypertension invasively measured during pulmonary vein isolation predicts atrial fibrillation recurrence.

Minerva Cardioangiol 2020 Dec 1. Epub 2020 Dec 1.

Electrophysiology and Cardiac Pacing Unit, San Maurizio Regional Hospital, Bolzano, Italy.

Background: The clinical role of left atrial hypertension (LAH) in patients with atrial fibrillation (AF) and its role as predictor in those undergoing pulmonary vein (PV) isolation is still unknown. The aim of the present study was to analyse the prevalence of LAH in patients with nonvalvular AF and preserved left ventricular ejection fraction who underwent PV isolation and its implication for AF catheter ablation.

Methods: Consecutive patients with drug resistant AF who underwent PV isolation at San Maurizio Regional Hospital of Bolzano (Italy) as index procedure were retrospectively included in this analysis. Left atrial hypertension was defined as the LA mean pressure ≥ 15 mm Hg.

Results: A total of 98 consecutive patients (71 males, 72%; mean age 60.3±8.4 years) were included in the analysis. Eleven patients (11%) underwent radiofrequency ablation and 87 (89%) cryoballoon ablation. The mean LA pressure was 11.7±5.5 mmHg; LAH occurred in 24 (24.5%) patients. At a mean follow up of 14.6±7.1 months (median 14 months), the success rate without antiarrhythmic therapy was 71.4% (70/98; considering the blanking period). Older age, LA volume and LAH were significantly associated with early AF recurrence during the blanking period. However, only LAH independently remained a significant predictor of late AF recurrence (HR 3.02, 1.36-6.72, p=0.007).

Conclusions: Left atrial hypertension was found in 24% of patients undergoing PV isolation and was found to be significantly related to both early and late AF recurrences.
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http://dx.doi.org/10.23736/S0026-4725.20.05418-3DOI Listing
December 2020

Worse Prognosis in Brugada Syndrome Patients With Arrhythmogenic Cardiomyopathy Features.

JACC Clin Electrophysiol 2020 10 12;6(11):1353-1363. Epub 2020 Aug 12.

Department of Cardiology, Oslo University Hospital, Rikshospitalet-Institute for Clinical Medicine, University of Oslo, Oslo, Norway. Electronic address:

Objectives: This study aimed to assess the presence of echocardiographic and electrocardiographic similarities in patients with Brugada syndrome (BrS) and arrhythmogenic cardiomyopathy (AC) and the prevalence and prognostic value of AC structural/electrical features in patients with BrS.

Background: BrS and AC are genetic cardiac diseases with high risk for sudden cardiac death. Although BrS and AC display different features, previous reports suggest a phenotypic overlap.

Methods: We acquired clinical data, electrocardiogram, and transthoracic echocardiography in patients with BrS and AC. We assessed the presence of AC diagnostic criteria according to the 2010 AC task force criteria for right ventricular outflow tract (RVOT), fractional area change, depolarization, and repolarization in the patients with BrS. We compared arrhythmic outcome in BrS patients with and without AC structural/electrical criteria.

Results: A total of 116 BrS and 141 AC patients were included. AC electrical features were present in 28 (24%) BrS patients and structural features in 97 (84%) BrS patients. BrS patients with an RVOT or depolarization AC criterion showed a trend towards worse severe arrhythmia-free survival compared to BrS patients without (p = 0.05). The criterion for RVOT dilation showed high sensitivity and improved detection of arrhythmic BrS patients when added to type 1 electrocardiogram pattern and syncope (area under the curve 0.73 [95% confidence interval: 0.59 to 0.87] vs. area under the curve 0.79 [95% confidence interval: 0.69 to 0.90]); p = 0.009).

Conclusions: In this large cohort comparison, Brugada syndrome (BrS) and arrhythmogenic cardiomyopathy patients had phenotypic overlap. The presence of arrhythmogenic cardiomyopathy diagnostic criteria in BrS patients was associated with a trend towards higher arrhythmic risk. The right ventricular outflow tract dilation criterion improved detection of arrhythmic BrS patients.
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http://dx.doi.org/10.1016/j.jacep.2020.05.026DOI Listing
October 2020

Long-term durability of posterior wall isolation using the cryoballoon in patients with persistent atrial fibrillation: a multicenter analysis of repeat catheter ablations.

J Interv Card Electrophysiol 2020 Sep 30. Epub 2020 Sep 30.

Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.

Purpose: There is a growing interest in performing pulmonary vein isolation (PVI) with concomitant posterior wall isolation (PWI) using the cryoballoon for the treatment of patients with persistent atrial fibrillation (AF). However, there is little known about the long-term durability of PWI using this approach.

Methods: In this multicenter study, we retrospectively examined the durability of PVI + PWI using the 28-mm cryoballoon by investigating the outcomes from consecutive patients referred for repeat catheter ablation.

Results: Altogether, 81/519 patients (15.6%) were referred for repeat catheter ablation. Repeat ablation was associated with a longer AF duration, hypertension, heart failure, multiple cardioversions, and antiarrhythmic therapy as well as larger left atrial (LA) diameters (49 ± 4 mm versus 43 ± 5 mm; P < 0.001) and greater need for "touch-up" (adjunct) radiofrequency ablation (44.4% versus 18.3%; P < 0.001). LA diameter also emerged as a significant predictor for adjunct radiofrequency ablation (P < 0.001). Durable PVI was observed in 66/81 patients (81.5%) and PWI in 67/81 patients (82.7%). Those with incomplete PWI exhibited larger LA diameters, particularly > 48 mm (negative predictive value = 89.7%). Lastly, an atypical LA posterior wall/roof flutter represented the third most common cause of arrhythmia recurrence and essentially every patient with incomplete PWI exhibited such an arrhythmia.

Conclusion: PWI performed using a 28-mm cryoballoon in conjunction with PVI exhibits long-term durability in the vast majority of patients with persistent AF. While LA diameter (particularly > 48 mm) is a significant predictor for the need for adjunct radiofrequency ablation when performing this technique, those with incomplete PWI invariably present with an atypical flutter using this substrate.
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http://dx.doi.org/10.1007/s10840-020-00887-8DOI Listing
September 2020

Correction to: Novel noncontact charge density map in the setting of post-atrial fibrillation atrial tachycardias: first experience with the Acutus SuperMap Algorithm.

J Interv Card Electrophysiol 2020 Sep 12. Epub 2020 Sep 12.

Heart Rhythm Management Center, Postgraduate program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.

The article "Novel noncontact charge density map in the setting of post-atrial fibrillation atrial tachycardias.
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http://dx.doi.org/10.1007/s10840-020-00860-5DOI Listing
September 2020

Ajmaline Testing and the Brugada Syndrome.

Am J Cardiol 2020 11 27;135:91-98. Epub 2020 Aug 27.

Heart Rhythm Management Center, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium; European Reference Networks Guard-Heart, Brussels, Belgium. Electronic address:

Brugada syndrome (BrS) diagnosis requires the presence of a typical type 1 ECG pattern. Owing to the spontaneous ECG variability, the real BrS prevalence in the general population remains unclear. The aim of the present study was to evaluate the prevalence of positive ajmaline challenge for BrS in a cohort of consecutive patients who underwent electrophysiological evaluation for different clinical reasons. All consecutive patients from 2008 to 2019 who underwent ajmaline testing were prospectively included. A total of 2,456 patients underwent ajmaline testing, 742 (30.2%) in the context of familial screening for BrS. In non-familial screening group (1,714) ajmaline testing resulted positive in 186 (10.9%). Indications for ajmaline testing were: suspicious BrS ECG in 23 cases (12.4%), palpitations in 27 (14.5%), syncope in 71 (38.2%), presyncope in 7 (3.8%), family history of sudden cardiac death in 18 (9.7%), documented ventricular arrhythmias in 12 (6.5%), unexplained cardiac arrest in 4 (2.2%), atrial fibrillation in 16 (8.5%), brady-arrhythmias in 1 (0.5%), and cerebrovascular accidents in 7 (3.7%). Compared with the overall population, ajmaline testing positive patients were younger (42.8 ± 15.5 vs 48.9 ± 20.4; p <0.001) and more frequently male (65.1% vs 56.3%; p = 0.023). Implantable cardioverter defibrillator was implanted in 84 patients (45.2%). During a median follow-up of 42.4 months, 12 appropriate shocks and 13 implantable cardioverter defibrillator related complications were reported. In conclusion, the BrS was diagnosed in an unexpected high proportion of patients that underwent ajmaline testing for a variety of cardiovascular symptoms. This can lead to an adequate counseling and clinical management in BrS patients.
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http://dx.doi.org/10.1016/j.amjcard.2020.08.024DOI Listing
November 2020

High-density mapping in patients undergoing ablation of atrial fibrillation with the fourth-generation cryoballoon and the new spiral mapping catheter.

Europace 2020 11;22(11):1653-1658

Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland.

Aims: To assess the value of high-density mapping (HDM) in revealing undetected incomplete pulmonary vein isolation (PVI) after the fourth-generation cryoballoon (CB4G) ablation compared to the previous cryoballoon's versions.

Methods And Results: Consecutive patients with paroxysmal or early-persistent atrial fibrillation (AF) undergoing CB ablation as the index procedure, assisted by HDM, were retrospectively included in this study. A total of 68 patients (52 males; mean age: 60 ± 12 years, 58 paroxysmal AF) were included, and a total of 272 veins were mapped. Fourth-generation cryoballoon with the new spiral mapping catheter (SMC) was used in 35 patients (51%). Time to PVI was determined in 102/132 (77%) and in 112/140 (80%) veins during second-generation cryoballoon/third-generation cryoballoon (CB2G/CB3G) and CB4G ablation, respectively (P = 0.66). There was a statistically significant difference in terms of discrepancy rate between the SMC and the mini-basket catheter in PV detection after CB4G and CB2G/CB3G ablation(1.4% vs. 7.6%; P = 0.01). A total of 57 patients (84%) remained free of symptomatic AF during a mean follow-up of 9.8 ± 4.6 months.

Conclusion: High-density mapping after cryoballoon ablation using CB4G and the new SMC identifies incomplete PVI, not detected by the new SMC, in a significantly lower proportion of veins compared to HDM performed after the other generation CB ablation.
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http://dx.doi.org/10.1093/europace/euaa160DOI Listing
November 2020

Electrophysiological findings in patients with isolated veins after cryoablation for paroxysmal atrial fibrillation.

J Cardiovasc Med (Hagerstown) 2020 Sep;21(9):641-647

Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels.

Aims: The main cause of atrial fibrillation recurrence after catheter ablation is pulmonary vein reconnection. The purpose of this retrospective study was to analyse the electophysiological findings in patients undergoing repeat procedures after an index cryoballoon ablation (CB-A) and presenting with permanency of pulmonary vein isolation (PVI) in all veins. In addition, we sought to compare the latter with a similar group of patients with reconnected veins at the redo procedure.

Methods: A total of 132 patients (81 men, 60.7 ± 12.4 years) who underwent CB-A for paroxysmal atrial fibrillation (PAF) were enrolled. Indication for the redo procedure was symptomatic PAF in 83 (63%), persistent atrial fibrillation (PerAF) in 32 (24%) or persistent regular atrial tachycardia (RAT) in 17 (13%) patients.

Results: Seventy-five (57%) patients presented a pulmonary vein reconnection (pulmonary vein group) during the redo procedure, whereas 57 (43%) had no pulmonary vein reconnection (non-pulmonary vein group). The non-pulmonary vein group exhibited significantly more non-pulmonary vein foci and atrial flutters than the pulmonary vein group after induction protocol (51 vs. 24%, P = 0.002 and 67 vs. 36%, P = 0.003, respectively). Twenty-two (29.3%) patients of the pulmonary vein group and 20 (35%) patients of the non-pulmonary vein group had atrial fibrillation/RAT recurrence after a mean follow-up of 12.5 ± 8 months. The survival analysis demonstrated no statistical significance in recurrence between both groups (log rank P = 0.358).

Conclusion: Atrial fibrillation/RAT recurrence in patients after CB-A with durable PVI is significantly associated with non-pulmonary vein foci and atrial flutters. No statistically different success rate regarding atrial fibrillation/RAT freedom was detected between the pulmonary vein and non-pulmonary vein groups after redoing RF-CA.
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http://dx.doi.org/10.2459/JCM.0000000000001045DOI Listing
September 2020

Novel noncontact charge density map in the setting of post-atrial fibrillation atrial tachycardias: first experience with the Acutus SuperMap Algorithm.

J Interv Card Electrophysiol 2020 Jul 8. Epub 2020 Jul 8.

Heart Rhythm Management Center, Postgraduate program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.

Purpose: The purpose of this study was to evaluate the safety and feasibility of the new high-resolution mapping algorithm SuperMap (Acutus Medical, CA, USA) in identifying and guiding ablation in the setting of regular atrial tachycardias following index atrial fibrillation (AF) ablation.

Methods: Seven consecutive patients who underwent a radiofrequency catheter ablation guided by the novel noncontact charge density (CD) SuperMap for atrial tachycardia were prospectively enrolled in our study.

Results: Arrhythmogenic substrate was identified in all seven patients. Mean number of EGM per map was 5859.7 ± 4348.5 points. Three patients (43%) exhibited focal tachycardia mechanisms in the left atrium, alternating from anteroseptal right superior pulmonary vein (RSPV), posterior in proximity of left inferior pulmonary vein (LIPV), and interarial septum in proximity of fossa ovalis, respectively. Four patients exhibited macroreentrant mechanism. In 3 of these patients, SuperMap detected mitral isthmus-dependent flutters with tachycardia cycle lengths of 240, 270 and 420 ms, respectively. In one patient, the mechanism was a macroreentrant tachycardia with the critical isthmus located between the crista terminalis and atriotomy. The mean ablation time (min) was 18.2 ± 12.5 and the mean procedural duration time was 56.4 ± 12.1 min. No minor or major complications occurred.

Conclusion: The novel high-resolution mapping algorithm SuperMap proved to be safe, fast, and feasible in identifying and guiding ablation in the setting of regular atrial tachycardias following index AF ablation.
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http://dx.doi.org/10.1007/s10840-020-00808-9DOI Listing
July 2020

Posterior box isolation as an adjunctive ablation strategy with the second-generation cryoballoon for paroxysmal atrial fibrillation: a comparison with standard cryoballoon pulmonary vein isolation.

J Interv Card Electrophysiol 2020 Jul 6. Epub 2020 Jul 6.

Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate Course in Cardiac Electrophysiology and Pacing, European Refernce Networks Guard-Heart, Vrije Universiteit, Brussels, Belgium.

Purpose: The purpose of the study was to evaluate the impact of left atrial posterior wall isolation (LAPWI) in addition to pulmonary vein isolation (PVI) vs PVI alone, performed using CB-A, in patients with PAF on a midterm follow-up of 12 months.

Methods: Eighty consecutive patients indicated to index cryoballoon ablation (CB-A) for the treatment of drug resistant PAF were included. The first 50 (62.5%) underwent PVI only, and the following 30 patients (37.5%) underwent LAPWI + PVI.

Results: Acute isolation was achieved in all PVs in both groups. The LAPW was successfully isolated in 29 out of 30 (97%) patients; in the remaining patient, adjunct radiofrequency ablation was required. The total procedure time and the mean fluoroscopy time were significantly shorter in patients who underwent PV isolation only (p < 0.001). The freedom from atrial fibrillation (AF) at 12 months was not significantly different between the 2 groups (LAPW + PVI = 90% vs PVI = 88%) (log-rank p = 0.816).

Conclusion: LAPW ablation in addition to PVI by the means of CB-A does not seem to reduce the risk of AF recurrence if compared with the standard PVI on a midterm follow-up of 12 months.
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http://dx.doi.org/10.1007/s10840-020-00812-zDOI Listing
July 2020

Electrocardiographic imaging of the arrhythmogenic substrate of Brugada syndrome: Current evidence and future perspectives.

Trends Cardiovasc Med 2020 Jun 15. Epub 2020 Jun 15.

Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Belgium. Electronic address:

Brugada syndrome is responsible for about 20% of sudden cardiac deaths in patients with apparently normal hearts. Basic and clinical research has elucidated some of the mechanisms that are responsible for life-threatening ventricular arrhythmias in this syndrome. Delays in activation and repolarization over the right ventricular outflow tract are the most likely cause of the ECG typical pattern and arrhythmogenesis. Invasive epicardial and endocardial mapping has identified the epicardium as the principal region of interest for these anomalies, and areas of fragmented potentials at invasive mapping are a target for epicardial ablation. Noninvasive mapping systems have been developed to study the epicardial depolarization and repolarization and may be particularly useful in assessing the epicardial arrhythmogenic substrate of Brugada syndrome for both clinical and research purpose. This review focuses on recent advances in this field.
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http://dx.doi.org/10.1016/j.tcm.2020.06.004DOI Listing
June 2020

Signal- or temperature-based approach for cryoballoon ablation of atrial fibrillation: still an unsolved issue.

J Interv Card Electrophysiol 2020 Dec 11;59(3):479-480. Epub 2020 Jun 11.

Heart Rhythm Management Center, UZ Brussel-VUB, Laarbeeklaan 101, 1090, Brussels, Belgium.

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http://dx.doi.org/10.1007/s10840-020-00792-0DOI Listing
December 2020

Temperature-guided ablation with the second-generation cryoballoon for paroxysmal atrial fibrillation: 3-year follow-up in a multicenter experience.

J Interv Card Electrophysiol 2020 May 31. Epub 2020 May 31.

Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.

Purpose: A strategy based on the attainment of the specific parameter of - 40 °C within the first 60 s during cryoenergy applications in the setting of cryoballoon ablation (CB-A) without the use of an inner lumen mapping catheter (ILMC) (Achieve; Medtronic, USA) for the visualization of real-time recordings (RTR) has been previously described. The latter has proven to be very effective in guaranteeing freedom from atrial arrhythmias in patients affected by paroxysmal atrial fibrillation (PAF) at 1-year follow-up. The purpose of this retrospective observational study was to evaluate the clinical outcomes of this strategy in a multicenter experience on a long-term follow-up of 3 years.

Methods: A total of 192 patients having undergone CB ablation for paroxysmal AF (PAF) starting from September 2015 to November 2016 that underwent a temperature-guided approach were included.

Results: Mean procedural time was 68.77 ± 18.88. The mean number of freezes in the LSPV was 1.2 ± 0.4, 1.2 ± 0.4 in the LIPV, 1.1 ± 0.4 in the RSPV, and 1.2 ± 0.4 in the RIPV. Considering a blanking period of 3 months, freedom from AF off-AAD was achieved in 77.6% (149/192) at mean 34.5 ± 5.5 months and median 35.1 months (IQR, 32.3-37.0 months) follow-up after 1 procedure.

Conclusions: A temperature-guided approach affords freedom from AF at a 3-year follow-up period in a large majority of patients affected by PAF having undergone a single CB-A procedure.
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http://dx.doi.org/10.1007/s10840-020-00770-6DOI Listing
May 2020

Long-term clinical outcomes after single freeze cryoballoon ablation for paroxysmal atrial fibrillation: a 5-year follow-up.

J Interv Card Electrophysiol 2020 May 29. Epub 2020 May 29.

Heart Rhythm Management Center, Universitair Ziekenhuis Brussel, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.

Background: The second-generation cryoballoon ablation (CB-A) has been proven to be safe and effective for pulmonary vein (PV) isolation. Little is known regarding the long-term outcome following CB-A ablation for paroxysmal atrial fibrillation (AF). The aim of the study was to evaluate the freedom from atrial arrhythmias during a 5-year follow-up period among consecutive patients having undergone PV isolation with the CB-A for paroxysmal AF METHODS AND RESULTS: A total of 208 consecutive patients having undergone index PV isolation using CB-A (138 males, 66%; mean age 59.0 ± 12.6 years) were included in our retrospective analysis. Follow-up was based on outpatient clinic visits including Holter electrocardiograms. Recurrence of atrial tachyarrhythmias was defined as a symptomatic or documented episode of > 30 s. At a median follow-up of 62 months, freedom from atrial arrhythmias after a single procedure was achieved in 57.2% of patients. Multivariate analysis demonstrated that obesity, left atrial diameter, and duration of symptoms before AF ablation were independent predictors of ATas recurrences. Major complications occurred in 2.4% of patients.

Conclusions: The present study found a 5-year single-procedure success rate of 57.2% following CB-A ablation procedure. Obesity, higher LA dimensions, and longer duration of symptoms before ablation independently predicted the outcome.
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http://dx.doi.org/10.1007/s10840-020-00788-wDOI Listing
May 2020

Cryoballoon ablation performed with a novel EP mapping system.

Europace 2020 06;22(6):931

Heart Rhythm Management Center, UZ Brussel-VUB, Laarbeeklaan 101, 1090 Brussels, Belgium.

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http://dx.doi.org/10.1093/europace/euaa078DOI Listing
June 2020

Recurrent Atrial Fibrillation After Cryoballoon Ablation: What to Expect!

Card Electrophysiol Clin 2020 06;12(2):199-208

Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium.

Atrial fibrillation (AF) recurrence following cryoballoon ablation may occur as a consequence of pulmonary vein (PV) reconnection, which can be treated effectively by performing repeat PV isolation. Alternatively, AF recurrence can manifest in presence of bilateral antral PV isolation. In such circumstances, one may pursue catheter ablation of AF triggers, if present, or proceed with empiric posterior left atrial wall ablation. Although traditionally, focal radiofrequency ablation has been used for this, cryoballoon ablation, itself, may also be used for ablation/isolation of certain structures such as the superior vena cava, the left atrial appendage and even the posterior left atrial wall.
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http://dx.doi.org/10.1016/j.ccep.2020.02.002DOI Listing
June 2020

Standardized Quantification of Vagal Denervation by Extracardiac Vagal Stimulation during Second Generation Cryoballoon ablation: a Vein per Vein Analysis.

J Atr Fibrillation 2019 Oct-Nov;12(3):2223. Epub 2019 Oct 31.

Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium.

Aims: The purpose of this study was to evaluate the contribution in the acute loss in vagal innervation after ablation with the second generation cryoballoon (CB-A) in each distinct pulmonary vein (PV) by means of external cardiac vagal stimulation (ECVS) by positioning a catheter in the internal jugular vein in a cohort of 60 patients.

Methods: Sixty patients, 50 starting from the left superior pulmonary vein (LSPV) and 10 from the right superior pulmonary vein with symptomatic paroxysmal atrial fibrillation (PAF), having undergone ECVS before the first and after each PV ablation by means of CB-A ablation, were included.

Results: The ECVS performed pre-ablation provoked cardioinhibitory responses in all cases with mean pause duration of 10251.83 ms ± 2826.23 ms. At the end of the procedure, the vagal reactions (VR) were significantly diminished. Specifically, compared against the initial pause, responses were 8957.06 ± 2711.66 ms (p < 0.01) after left superior PV, 10017.36 ± 9127.0 ms (p = 0.88) after left inferior PV, 6020.16 ± 3780.709 ms (p < 0.001) after right inferior PV and 1687.5 ± 2183.7 ms (p < 0.001) after right superior PV. Noteworthy, if starting with ablation in the RSPV, VR was immediately reduced by 90.34%, 990.7 ± 379.78 ms (p < 0.001) as compared to baseline response.

Conclusion: Although not directly targeting the ganglion plexuses, AF ablation with the CB-A causes a significant acute loss in parasympathetic innervation. The RSPV showed to be associated with the most significant reduction of acute loss in parasympathetic innervation.
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http://dx.doi.org/10.4022/jafib.2223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237095PMC
October 2019

Long-term follow up of second-generation cryoballoon-based pulmonary vein isolation: Lights and shadows.

Int J Cardiol 2020 08 28;312:71-72. Epub 2020 Apr 28.

Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium.

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http://dx.doi.org/10.1016/j.ijcard.2020.04.078DOI Listing
August 2020

Safety and feasibility of electrical isolation of the superior vena cava in addition to pulmonary vein ablation for paroxysmal atrial fibrillation using the cryoballoon: lessons from a prospective study.

J Interv Card Electrophysiol 2021 Mar 6;60(2):255-260. Epub 2020 Apr 6.

Heart Rhythm Management Center, Postgraduate program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, Brussels, Belgium.

Purpose: The purpose of this study was to evaluate the feasibility and safety of superior vena cava (SVC) isolation in addition to standard pulmonary vein isolation (PVI) using the second-generation cryoballoon (CB) in patients with paroxysmal atrial fibrillation.

Methods: Thirty-seven consecutive patients that underwent CB ablation for paroxysmal atrial fibrillation (PAF) were prospectively enrolled in our study. After PVI the SVC was mapped for potentials. If the SVC exhibited electrical activity, isolation was achieved performing a single 180-s balloon application.

Results: Regarding SVC isolation, 180-s freeze in the SVC could be completed in 32 (86.4%) patients, and 5 patients had at least 120 s of freezing application (13.5%). Real-time recording during SVC isolation was observed in 30 (81.0%) patients. The mean time to isolation was 36.9 ± 28.7 s and the temperature at isolation was - 33 (- 15 to - 40) °C. No cases developed persistent phrenic nerve palsy (PNP) or any other complication.

Conclusions: Superior vena cava isolation proved to be safe and feasible with the second generation cryoballoon in a prospective series of patients affected by PAF.
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http://dx.doi.org/10.1007/s10840-020-00740-yDOI Listing
March 2021

A case of Brugada pattern "bigeminy".

Pacing Clin Electrophysiol 2020 05 24;43(5):524-526. Epub 2020 Apr 24.

Heart Rhythm Management Centre, UZ Brussel-VUB, Brussels, Belgium.

The present case reports for the first time an unusual presentation of Brugada type 1 pattern occurring in a "bigeminy way" without no drug challenges or any apparent causes in a family member of a proband with type 1 pattern.
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http://dx.doi.org/10.1111/pace.13909DOI Listing
May 2020

A novel strategy to treat vaso-vagal syncope: Cardiac neuromodulation by cryoballoon pulmonary vein isolation.

Indian Pacing Electrophysiol J 2020 Jul - Aug;20(4):154-159. Epub 2020 Mar 26.

Heart Rhythm Management Center, UZ Brussel-VUB, Laarbeeklaan 101, 1090, Brussels, Belgium.

Background: Clinical management of vaso-vagal syncope (VVS) remains challenging since no therapy has proven to completely prevent VVS recurrence.

Objective: The purpose of this study was to analyze the mid-term outcome of cryoballoon (CB) cardioneuroablation achieved by pulmonary vein isolation (PVI) in patients with VVS.

Methods: Patients who underwent CB cardioneuroablation in our centers between January 2014 to June 2018 were included. All patients had a history of VVS or pre-syncope despite therapeutic attempts with medical and/or pacing treatments. Patients were excluded in case of structural heart diseases, cerebrovascular diseases or suspected drug-related syncope. Both heart rate (HR) and atrio-ventricular (AV) interval were analyzed on the 12-lead electrocardiogram (ECG) the day before the procedure, the day after, and in the follow-up.

Results: In total, 26 patients (76.9% males, 37.5 ± 9.0 years old) were included. All patients underwent a successful procedure with the 28 mm second-generation Arctic Front Advance CB. No major complication occurred. At a mean follow-up of 20.1 ± 11.6 months the freedom from VVS or reflex pre-syncope was 83,7%, with 22 patients free from any clinical recurrence. Basal HR significantly increased the day after the procedure (57.2 bpm vs 78.3 bpm, p < 0.001), while at the final follow-up it stabilized at a value halfway between the 2 previous ones (69.8 bpm, p = 0.0086). The AV interval didn't modify significantly after the procedure.

Conclusion: Endocardial autonomic denervation achieved by CB PVI appears to be an effective and safe treatment option for patients with refractory VVS and reflex pre-syncope.
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http://dx.doi.org/10.1016/j.ipej.2020.03.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371945PMC
March 2020