Publications by authors named "Isabelle Nault"

99 Publications

Ambulatory Electrocardiogram Monitoring in Patients Undergoing Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review.

J Am Coll Cardiol 2021 Mar;77(10):1344-1356

Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; Hospital Clínic de Barcelona, Barcelona, Spain. Electronic address:

Transcatheter aortic valve replacement (TAVR) has changed the treatment of patients with severe aortic stenosis. However, the occurrence of conduction disturbances has not decreased significantly over time and remains the main drawback of the procedure. In addition, new-onset atrial fibrillation is the most frequent tachyarrhythmia during the hospitalization period and is associated with worse clinical outcomes. However, little is known regarding the incidence and clinical impact of arrhythmic events beyond the periprocedural TAVR period. Ambulatory electrocardiogram (AECG) monitoring has recently emerged as a tool to unravel the complex issue of arrhythmic disorders (bradyarrhythmias and tachyarrhythmias) before and after TAVR. To date, the preliminary results from the initial experience using AECG monitoring systems showed the safety, usefulness, and potential clinical implications of this diagnostic tool in TAVR recipients. This review provides an overview of the current status, clinical implications, and future perspectives of AECG monitoring in the TAVR setting.
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http://dx.doi.org/10.1016/j.jacc.2020.12.062DOI Listing
March 2021

Twiddler Syndrome without Lead Dislodgment Discovered by Remote Monitoring.

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

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

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

Response to letter to editor: Safety of long-term remote-only monitoring of implantable cardioverter defibrillators.

Pacing Clin Electrophysiol 2021 Mar 11;44(3):565. Epub 2021 Feb 11.

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

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http://dx.doi.org/10.1111/pace.14179DOI Listing
March 2021

Remote-only monitoring for patients with cardiac implantable electronic devices: a before-and-after pilot study.

CMAJ Open 2021 Jan-Mar;9(1):E53-E61. Epub 2021 Jan 25.

QEII Health Sciences Centre, Dalhousie University (Sapp, AbdelWahab, Parkash), Halifax, NS; Department of Cardiac Sciences (Gillis, Raj), University of Calgary, Calgary, Alta.; Institut universitaire de cardiologie and pneumologie de Quebec (Nault, Philippon), Université Laval, Québec, Que.; University of Ottawa Heart Institute (Nery, Wells), Ottawa, Ont.; Hamilton Health Sciences (Healey), McMaster University, Hamilton, Ont.; CK Hui Heart Centre (Lockwood), Edmonton, Alta.; Vancouver Island Health Authority (Sterns), Victoria, BC; East Carolina University (Sears), Greenville, NC; London Health Sciences Centre (Yee, Tang), University of Western Ontario, London, Ont.

Background: Outcomes for patients with cardiac implantable electronic devices are better when follow-up incorporates remote monitoring technology in addition to in-clinic visits. For patients with implantable devices, we sought to determine the feasibility, safety and associated health care utilization of remote-only follow-up, along with its effects on patients' quality of life and costs.

Methods: This multicentre before-and-after pilot study involved patients with new or existing pacemakers or implantable cardioverter defibrillators. The "before" phase of the study spanned the period October 2015 to February 2017; the "after" phase spanned the period October 2016 to February 2018. The exposure was remote-only follow-up in combination with Remote View, a service that facilitates access to device data, allowing device settings to be viewed remotely to facilitate remote programming. Outcomes at 12 months were feasibility (adherence to remote monitoring), safety (rate of adverse events) and health care utilization (remote and in-clinic appointments). We also assessed quality of life, using 3 validated scales, and costs, taking into account both health care system and patient costs.

Results: A total of 176 patients were enrolled. Adherence (defined as at least 1 successful remote transmission during follow-up) was 87% over a mean follow-up of 11.7 (standard deviation 2.2) months. There was a reduction in in-clinic visits at specialized sites among patients with both implantable defibrillators (26 v. 5, < 0.001, = 48) and pacemakers (42 v. 10, < 0.001, = 51). There was no significant change in visits to community sites for patients with defibrillators (13 v. 17, = 0.3, = 48). The composite rate of death, stroke, cardiovascular hospitalization and device-related hospitalization was 7% ( = 164). No adverse events were linked to the intervention. There was no change in quality-of-life scales between baseline and 12 months. Health care costs were reduced by 31% for patients with defibrillators and by 44% for those with pacemakers.

Interpretation: This pilot study showed the feasibility of remote-only follow-up, with no increase in adverse clinical outcomes and no effect on quality of life, but with reductions in costs and health care utilization. These results support progression to a larger-scale study of whether superior effectiveness and reduced cost can be achieved, with preservation of safety, through use of remote-only follow-up.

Trial Registration: ClinicalTrials.gov, no. NCT02585817.
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http://dx.doi.org/10.9778/cmajo.20200041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7843075PMC
January 2021

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

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

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

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

Pulmonary Vein Stenosis After Atrial Fibrillation Ablation: Insights From the ADVICE Trial.

Can J Cardiol 2020 Dec 3;36(12):1965-1974. Epub 2020 Nov 3.

Montréal Heart Institute, University of Montréal, Montréal, Québec, Canada. Electronic address:

Background: Pulmonary vein (PV) stenosis is a complication of atrial fibrillation (AF) ablation. The incidence of PV stenosis after routine post-ablation imaging remains unclear and is limited to single-centre studies. Our objective was to determine the incidence and predictors of PV stenosis following circumferential radiofrequency ablation in the multicentre Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination (ADVICE) trial.

Methods: Patients with symptomatic AF underwent circumferential radiofrequency ablation in one of 13 trial centres. Computed tomographic (CTA) or magnetic resonance (MRA) angiography was performed before ablation and 90 days after ablation. Two blinded reviewers measured PV diameters and areas. PVs with stenosis were classified as severe (> 70%), moderate (50%-70%), or mild (< 50%). Predictors of PV stenosis were identified by means of multivariable logistic regression.

Results: A total of 197 patients (median age 59.5 years, 29.4% women) were included in this substudy. PV stenosis was identified in 41 patients (20.8%) and 47 (8.2%) of 573 ablated PVs. PV stenosis was classified as mild in 42 PVs (7.3%) and moderate in 5 PVs (0.9%). No PVs had severe stenosis. Both cross-sectional area and diameter yielded similar classifications for severity of PV stenosis. Diabetes was associated with a statistically significant increased risk of PV stenosis (OR 4.91, 95% CI 1.45-16.66).

Conclusions: In the first systematic multicentre evaluation of post-ablation PV stenosis, no patient acquired severe PV stenosis. Although the results are encouraging for the safety of AF ablation, 20.8% of patients had mild or moderate PV stenosis, in which the long-term effects are unknown.
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http://dx.doi.org/10.1016/j.cjca.2020.10.013DOI Listing
December 2020

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

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

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

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

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

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

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

Impact of Female Sex on Clinical Presentation and Ablation Outcomes in the CIRCA-DOSE Study.

JACC Clin Electrophysiol 2020 08 29;6(8):945-954. Epub 2020 Jul 29.

Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada. Electronic address:

Objectives: This study sought to evaluate sex-specific differences in atrial fibrillation (AF) presentation and catheter ablation outcomes in the prospective, multicenter, randomized CIRCA-DOSE (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration) study.

Background: Similar to other cardiovascular conditions, significant sex-specific differences have been observed in the epidemiology, pathophysiology, presentation, and natural history of AF. Unfortunately, there are major gaps in our understanding of the pathophysiological basis for the observed sex-specific differences and their implications on therapy and prognosis.

Methods: This study examined sex-specific differences in AF presentation, symptom severity and health-related quality of life, symptomatic and asymptomatic arrhythmia recurrence, AF burden, and health care utilization.

Results: Freedom from any atrial tachyarrhythmia and symptomatic atrial tachyarrhythmia were similar between male (hazard ratio: 1.18; 95% confidence interval: 0.85 to 1.64; p = 0.39) and female patients (hazard ratio: 1.00; 95% confidence interval: 0.62 to 1.59; p = 0.92). Post-ablation, the median AF burden (percentage time in AF) was 0.00% (interquartile range: 0.00% to 0.16%) in male patients and 0.00% (interquartile range: 0.00% to 0.17%) in female patients, with no difference observed between the sexes (p = 0.30). Periprocedural complications occurred twice as frequently in female patients (3.5% vs. 7.0%; p = 0.18). In comparison to male patients, female patients reported a significantly worse symptom score and quality of life at baseline and all follow-up intervals, but they derived similar magnitude of improvement post-ablation. There was no difference between male and female patients with respect to emergency department visits, hospitalization, cardioversion, or repeat ablation.

Conclusions: When compared with male patients, female patients have significantly worse symptom scores and quality of life at baseline. Despite this, female patients with symptomatic paroxysmal AF derive similar benefit in freedom from recurrent arrhythmia and similar improvements in quality of life following AF ablation. (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration [CIRCA-DOSE]; NCT01913522).
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http://dx.doi.org/10.1016/j.jacep.2020.04.032DOI Listing
August 2020

Prolonged Continuous Electrocardiographic Monitoring Prior to Transcatheter Aortic Valve Replacement: The PARE Study.

JACC Cardiovasc Interv 2020 08 15;13(15):1763-1773. Epub 2020 Jul 15.

Quebec Heart and Lung Institute, Laval University, Quebec City, Canada. Electronic address:

Objectives: This study sought to determine, using continuous electrocardiographic monitoring (CEM) pre-transcatheter aortic valve replacement (TAVR), the incidence and type of unknown pre-existing arrhythmic events (AEs) in TAVR candidates, and to evaluate the occurrence and impact of therapeutic changes secondary to the detection of AEs pre-TAVR.

Background: Scarce data exist on the arrhythmic burden of TAVR candidates (pre-procedure).

Methods: This was a prospective study including 106 patients with severe aortic stenosis and no prior permanent pacemaker screened for TAVR. A prolonged (1 week) CEM was implanted within the 3 months pre-TAVR. Following heart team evaluation, 90 patients underwent elective TAVR.

Results: New AEs were detected by CEM in 51 (48.1%) patients, leading to a treatment change in 14 of 51 (27.5%) patients. Atrial fibrillation or tachycardia was detected in 8 of 79 (10.1%) patients without known atrial fibrillation or tachycardia, and nonsustained ventricular arrhythmias were detected in 31 (29.2%) patients. Significant bradyarrhythmias were observed in 22 (20.8%) patients, leading to treatment change and permanent pacemaker in 8 of 22 (36.4%) and 4 of 22 (18.2%) patients, respectively. The detection of bradyarrhythmias increased up to 30% and 47% among those patients with pre-existing first-degree atrioventricular block and right bundle branch block, respectively. Chronic renal failure, higher valve calcification, and left ventricular dysfunction determined (or tended to determine) an increased risk of AEs pre-TAVR (p = 0.028, 0.052, and 0.069, respectively). New onset AEs post-TAVR occurred in 22.1% of patients, and CEM pre-TAVR allowed early arrhythmia diagnosis in one-third of them.

Conclusions: Prolonged CEM in TAVR candidates allowed identification of previously unknown AEs in nearly one-half of the patients, leading to prompt therapeutic measures (pre-TAVR) in about one-fourth of them. Pre-existing conduction disturbances (particularly right bundle branch block) and chronic renal failure were associated with a higher burden of AEs.
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http://dx.doi.org/10.1016/j.jcin.2020.03.031DOI Listing
August 2020

2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Position Statement on the Management of Ventricular Tachycardia and Fibrillation in Patients With Structural Heart Disease.

Can J Cardiol 2020 06;36(6):822-836

Department of Medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.

This Canadian Cardiovascular Society position statement is focused on the management of sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) that occurs in patients with structural heart disease (SHD), including previous myocardial infarction, dilated cardiomyopathy, and other forms of nonischemic cardiomyopathy. This patient population is rapidly increasing because of advances in care and improved overall survival of patients with all forms of SHD. In this position statement, the acute and long-term management of VT/VF are outlined, and the many unique aspects of care in this population are emphasized. The initial evaluation, acute therapy, indications for chronic suppressive therapy, choices of chronic suppressive therapy, implantable cardioverter-defibrillator programming, alternative therapies, and psychosocial care are reviewed and recommendations for optimal care are provided. The target audience for this statement includes all health professionals involved in the continuum of care of patients with SHD and VT/VF.
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http://dx.doi.org/10.1016/j.cjca.2020.04.004DOI Listing
June 2020

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

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

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

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

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

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

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

Large-scale implementation of a pragmatic atrial fibrillation screening program in Canadian community practice.

Pacing Clin Electrophysiol 2020 07 11;43(7):768-769. Epub 2020 Jun 11.

Department of Medicine, Université Laval, Quebec City, Canada.

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http://dx.doi.org/10.1111/pace.13966DOI Listing
July 2020

Blinded Randomized Trial of Anticoagulation to Prevent Ischemic Stroke and Neurocognitive Impairment in Atrial Fibrillation (BRAIN-AF): Methods and Design.

Can J Cardiol 2019 08 7;35(8):1069-1077. Epub 2019 May 7.

Department of Medicine, Université de Montréal, Montréal, Québec, Canada.

Background: Compelling evidence showing a link between atrial fibrillation (AF) and cognitive decline and dementia is accumulating.

Methods: Blinded Randomized Trial of Anticoagulation to Prevent Ischemic Stroke and Neurocognitive Impairment in Atrial Fibrillation (BRAIN-AF) is a prospective, multicentric, double-blind, randomized-controlled trial, recruiting patients with nonvalvular AF and a low risk of stroke. Patients with a high risk of bleeding will be excluded from the study. Participants will be randomized to receive either rivaroxaban (15 mg daily) or standard of care (placebo in patients without vascular disease or acetylsalicylic acid 100 mg daily in patients with vascular disease).

Results: The primary outcome is the composite of stroke, transient ischemic attack, and cognitive decline (defined by a decrease in the Montreal Cognitive Assessment score ≥ 3 at any follow-up visit after baseline). Approximately 3250 patients will be enrolled in approximately 130 clinical sites until 609 adjudicated primary outcome events have occurred.

Conclusions: BRAIN-AF determines whether oral anticoagulation therapy with rivaroxaban compared with standard of care reduces the risk of stroke, transient ischemic attack, or cognitive decline in patients with nonvalvular AF and a low risk of stroke.
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http://dx.doi.org/10.1016/j.cjca.2019.04.022DOI Listing
August 2019

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

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

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

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

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

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

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

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

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

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

Prognostic Value of Noninducibility on Outcomes of Ventricular Tachycardia Ablation: A VANISH Substudy.

JACC Clin Electrophysiol 2018 07 30;4(7):911-919. Epub 2018 May 30.

Department of Medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Canada.

Objectives: This study sought to evaluate the predictive value of noninducibility on long-term outcomes.

Background: The traditional endpoint for catheter ablation of ventricular tachycardia (VT) is noninducibility of VT by programmed stimulation; however, the definition of inducibility remains variable and its prognostic value limited by nonstandardized periprocedural antiarrhythmic drug therapy and implantable cardioverter-defibrillator programming in prior observational studies. The VANISH trial randomized patients with prior myocardial infarction and VT to ablation (with an endpoint of noninducibility of VT ≥300 ms after ablation) versus antiarrhythmic drug escalation.

Methods: Patients enrolled in the VANISH study randomized to catheter ablation were included. The relationship between post-ablation inducibility and the primary composite endpoint (death, VT storm >30 days, or appropriate implantable cardioverter-defibrillator shock >30 days) was assessed using a time-to-event analysis, adjusting for other clinical and procedural characteristics.

Results: A total of 129 patients from the ablation arm were included in the primary analysis, of which 51 were noninducible post-ablation compared with 78 who had inducible VT or in whom inducibility testing was not performed. There were no significant baseline characteristic or procedural differences except for increased implantable cardioverter-defibrillator shocks before randomization in the noninducible group. In multivariate analysis, inducibility significantly increased the risk of death, appropriate shock, or VT storm after 30 days (HR: 1.87; p = 0.017).

Conclusions: Inducibility of any VT post-ablation was associated with an increased risk of the composite endpoint in the VANISH trial. A randomized trial is required to confirm whether more aggressive ablation targeting faster induced VTs (<300 ms) can improve outcomes.
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http://dx.doi.org/10.1016/j.jacep.2018.03.013DOI Listing
July 2018

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

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

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

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

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

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

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

Cost Effectiveness of Ventricular Tachycardia Ablation Versus Escalation of Antiarrhythmic Drug Therapy: The VANISH Trial.

JACC Clin Electrophysiol 2018 05 28;4(5):660-668. Epub 2018 Mar 28.

Department of Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Canada. Electronic address:

Objectives: This analysis uses the data from the randomized controlled trial to assess the cost effectiveness of catheter ablation (n = 132) versus escalated antiarrhythmic therapy (n = 127).

Background: For survivors of myocardial infarction with implantable cardioverter-defibrillator shocks despite antiarrhythmic drugs, the VANISH (Ventricular Tachycardia Ablation Versus Escalated Antiarrhythmic Drug Therapy in Ischemic Heart Disease) trial demonstrated improved clinical outcomes with catheter ablation compared with more aggressive antiarrhythmic pharmacotherapy.

Methods: Health care resource use and quality-of-life data were used to determine the cost effectiveness of catheter ablation. Published references were used to estimate costs (in 2015 Canadian dollars). The analysis was over 3 years, with a 5% discount rate. Adjustment was made for censoring and baseline utilities.

Results: Ablation resulted in greater quality-adjusted life-years (QALYs) than escalated drug therapy did (1.63 vs. 1.49; difference: 0.14; 95% confidence interval [CI]: -0.20 to 0.46) and higher cost ($65,126 vs. $60,269; difference: $4,857; 95% CI: -$19,757 to $27,106); with an incremental cost per QALY gained for ablation versus escalated drug therapy of $34,057 primarily due to the initial costs of ablation, which were partially offset by the costs of subsequent ablations and adverse outcomes in the escalated drug therapy arm. For patients with amiodarone-refractory ventricular tachycardia, ablation dominated escalated drug therapy, with greater QALYs (1.48 vs. 1.26; difference: 0.22; 95% CI: -0.19 to 0.59) and lower costs ($67,614 vs. $68,383; difference: -$769; 95% CI: -$35,330 to $27,092). For those with sotalol-refractory ventricular tachycardia, ablation resulted in similar QALYs (1.90 vs. 1.90; difference: -0.00; 95% CI: -0.59 to 0.62) and higher costs ($60,455 vs. $45,033; difference: $15,422; 95% CI: -$10,968 to $48,555).

Conclusions: For the total trial population, results are suggestive that ablation is cost effective compared with escalation of drug therapy. This result was only manifest for the subgroup of patients whose qualifying arrhythmia occurred despite amiodarone.
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http://dx.doi.org/10.1016/j.jacep.2018.01.007DOI Listing
May 2018

Mexiletine or catheter ablation after amiodarone failure in the VANISH trial.

J Cardiovasc Electrophysiol 2018 04 1;29(4):603-608. Epub 2018 Feb 1.

Department of Medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.

Introduction: In patients with ischemic heart disease and ventricular tachycardia (VT) refractory to high dose amiodarone, the two most common therapeutic options are adjunctive mexiletine therapy or catheter ablation. There are little existing data on the efficacy of these strategies. We examined the relative efficacy of adjunctive mexiletine and catheter ablation among patients enrolled in the VANISH trial.

Methods: All subjects enrolled in the VANISH trial who had VT refractory to high dose (≥ 300 mg daily) amiodarone at baseline were included. Per protocol, subjects randomized to escalated drug therapy received adjunctive mexiletine.

Results: Nineteen of the 259 patients were receiving high-dose amiodarone at baseline and 11 were randomized to escalated therapy with mexiletine and 8 to ablation. The adjunctive mexiletine group had a higher rate of the primary composite outcome (death, VT storm, or appropriate shock) in comparison to catheter ablation (HR 6.87 [2.08-22.8]). Over 90% of the patients in the adjunctive mexiletine/group experienced a primary endpoint during a median 9.2 months' follow-up. There was no difference in the rate of adverse events between the two groups.

Conclusions: Mexiletine has limited efficacy in the treatment of recurrent VT despite high-dose amiodarone therapy, in patients with ischemic heart disease. Catheter ablation is a superior strategy in this population.
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http://dx.doi.org/10.1111/jce.13431DOI Listing
April 2018

Effect of Baseline Antiarrhythmic Drug on Outcomes With Ablation in Ischemic Ventricular Tachycardia: A VANISH Substudy (Ventricular Tachycardia Ablation Versus Escalated Antiarrhythmic Drug Therapy in Ischemic Heart Disease).

Circ Arrhythm Electrophysiol 2018 01;11(1):e005663

From the QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Canada (I.N.); Montreal Heart Institute, Quebec, Canada (L.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); McGill University Health Center, Montreal, Quebec, Canada (V.E.); Hôpital Sacré-Coeur de Montréal, Quebec, Canada (V.E.); University of Ottawa Heart Institute, Ontario, Canada (P.N., G.W.); Royal Columbian Hospital, Vancouver, British Columbia, Canada (S.T.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (J.-M.R.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (L.S.); Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada (S.D.); and Brigham and Women's Hospital, Boston, MA (W.G.S.).

Background: The VANISH trial (Ventricular Tachycardia Ablation Versus Escalated Antiarrhythmic Drug Therapy in Ischemic Heart Disease) compared the effectiveness of escalated antiarrhythmic drug therapy to catheter ablation in patients with prior myocardial infarction, an implanted defibrillator, and ventricular tachycardia (VT). The effectiveness of these interventions in patients on sotalol versus amiodarone was compared.

Methods And Results: Analysis was conducted based on whether patients had recurrent VT, despite amiodarone (amio-refractory) or nonamiodarone drugs (sotalol-refractory). Outcomes included death, VT storm, appropriate implantable cardioverter defibrillator shock, and any ventricular arrhythmia. At baseline, 169 (65.2%) were amio-refractory, and 90 (34.7%) were sotalol-refractory (1 patient on procainamide rather than sotalol). Amio-refractory patients had more renal insufficiency (23.7% versus 10%; =0.0008), worse New York Heart Association class (82.3% II/III versus 65.5%; =0.0003), and lower ejection fraction (29±9.7% versus 35.2±11%; <0.0001). Within the amio-refractory group, ablation resulted in reduction of any ventricular arrhythmia compared with escalated drug therapy (hazard ratio, 0.53; 95% confidence interval, 0.31-0.9), =0.020). Sotalol-refractory patients had trends toward higher mortality and VT storm with ablation, with no effect on implantable cardioverter defibrillator shocks. Within the escalated drug therapy arm, amio-refractory patients had a higher rate of the composite outcome (hazard ratio, 1.94; 95% confidence interval, 1.14-3.29; =0.0144) and a trend to higher mortality (hazard ratio, 2.40; 95% confidence interval, 0.93-6.22; =0.07), whereas mortality was not different between amio- and sotalol-refractory patients within the ablation treatment group.

Conclusions: Patients with amio-refractory VT have a higher rate of ventricular arrhythmia and mortality than those with sotalol-refractory VT and derive greater benefit of catheter ablation than for patients with sotalol-refractory VT who are switched to amiodarone.

Clinical Trial Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT00905853.
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http://dx.doi.org/10.1161/CIRCEP.117.005663DOI Listing
January 2018

Effect of Aggressive Blood Pressure Control on the Recurrence of Atrial Fibrillation After Catheter Ablation: A Randomized, Open-Label Clinical Trial (SMAC-AF [Substrate Modification With Aggressive Blood Pressure Control]).

Circulation 2017 May 22;135(19):1788-1798. Epub 2017 Feb 22.

From Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada (R.P., J.L.S., C.G., M.G.); University of Ottawa Heart Institute, Ontario, Canada, (G.A.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H.); Montreal Heart Institute, Quebec, Canada (J.-C.T., L.R.); Centre Hospitalier de L'Universite de Montreal, Quebec, Canada (I.G.); Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada (J.-F.R.); University of Western Ontario, London, Canada (L.G., A.S.L.T.); Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Canada (I.N.); Royal Jubilee Hospital, Victoria, British Columbia, Canada (P.N.); Ottawa Heart Institute, Ontario, Canada (D.B.); University Health Network, Toronto, Ontario, Canada (A.H.); Libin Cardiovascular Institute of Alberta, Calgary, Canada (S.B.W.); and St. Michael's Hospital, Toronto, Ontario, Canada (I.M.).

Background: Radiofrequency catheter ablation for atrial fibrillation has become an important therapy for AF; however, recurrence rates remain high. We proposed to determine whether aggressive blood pressure (BP) lowering prevents recurrent atrial fibrillation (AF) after catheter ablation in patients with AF and a high symptom burden.

Methods: We randomly assigned 184 patients with AF and a BP >130/80 mm Hg to aggressive BP (target <120/80 mm Hg) or standard BP (target <140/90 mm Hg) treatment before their scheduled AF catheter ablation. The primary outcome was symptomatic recurrence of AF/atrial tachycardia/atrial flutter lasting >30 seconds, determined 3 months beyond catheter ablation by a blinded end-point evaluation.

Results: The median follow-up was 14 months. At 6 months, the mean systolic BP was 123.2±13.2 mm Hg in the aggressive BP treatment group versus 135.4±15.7 mm Hg (<0.001) in the standard treatment group. The primary outcome occurred in 106 patients, 54 (61.4%) in the aggressive BP treatment group compared with 52 (61.2%) in the standard treatment group (hazard ratio=0.94; 95% confidence interval, 0.65-1.38; =0.763). In the prespecified subgroup analysis of the influence of age, patients ≥61 years of age had a lower primary outcome event rate with aggressive BP (hazard ratio=0.58; 95% confidence interval, 0.34-0.97; =0.013). There was a higher rate of hypotension requiring medication adjustment in the aggressive BP group (26% versus 0%).

Conclusions: In this study, this duration of aggressive BP treatment did not reduce atrial arrhythmia recurrence after catheter ablation for AF but resulted in more hypotension.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00438113.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.116.026230DOI Listing
May 2017

Predictors of Ventricular Arrhythmias and Sudden Death in a Québec Cohort With Brugada Syndrome.

Can J Cardiol 2016 11 31;32(11):1355.e1-1355.e7. Epub 2016 Mar 31.

Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada; Montréal Health Innovations Coordinating Center (MHICC), Montréal Heart Institute, Montréal, Québec, Canada.

Background: Patients with Brugada syndrome (BrS) are at risk for ventricular arrhythmias (VAs) and sudden death. Identification of high-risk individuals beyond those with syncope or resuscitated sudden death remains a major challenge.

Methods: We assessed the value of clinical, electrophysiological, and electrocardiographic (ECG) features, including depolarization and repolarization metrics, in predicting arrhythmic events and sudden death in consecutive patients with BrS diagnosed between 2002 and 2013 in Quebec, Canada. Qualifying electrocardiograms with the highest type 1 ST-segment elevations were reviewed and analyzed by 2 electrophysiologists who were blinded to clinical history. Survival analyses were adjusted for Firth bias correction and left truncation.

Results: A total of 105 patients, 79.8% of whom were men, were diagnosed with BrS at a mean age of 46.2 ± 13.3 years and were followed for 59.6 ± 16.4 months. Ten (9.5%) had a history of cardiac arrest, 37 (35.2%) had syncope, and 7 (6.7%) experienced 20 arrhythmic events during follow-up, all consisting of appropriate ICD therapy (7 antitachycardia pacing; 13 shocks). In multivariate Cox regression analyses, a spontaneous type 1 electrocardiographic (ECG) pattern (hazard ratio [HR], 10.80; 95% confidence interval [CI], 1.03-113.87; P = 0.0476), maximal T peak-end (T) duration ≥ 100 ms (HR, 29.73; 95% CI, 1.33-666.37; P = 0.0325), and QRS duration in lead V > 110 ms (HR, 15.27; 95% CI, 1.07-217.42; P = 0.0443) were independently associated with VAs or aborted sudden cardiac death.

Conclusions: In a multicentre cohort with BrS from Quebec, Canada, VAs and sudden death were independently associated with standard 12-lead ECG features, including a spontaneous type 1 pattern, depolarization (QRS in lead V), and repolarization (maximal T duration) criteria.
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http://dx.doi.org/10.1016/j.cjca.2016.03.012DOI Listing
November 2016

Contact-Force Catheters: Efficacy Versus Safety? Case Report of 2 Atrioesophageal Fistulae.

J Cardiovasc Electrophysiol 2016 12 13;27(12):1483-1487. Epub 2016 Oct 13.

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

Contact-force (CF) catheters appear to be more effective compared to standard ablation catheters for complex radiofrequency ablation including atrial fibrillation (AF) ablation when optimal CF >10 g is achieved. Some have suggested that this technology could also improve procedural safety. We report 2 cases of atrioesophageal fistulae (AEF), a rare but catastrophic complication of AF ablation. These are to our knowledge the first cases of AEF described after using CF catheters.
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http://dx.doi.org/10.1111/jce.13079DOI Listing
December 2016

Programmed Ventricular Stimulation for Risk Stratification in the Brugada Syndrome: A Pooled Analysis.

Circulation 2016 Feb 21;133(7):622-30. Epub 2016 Jan 21.

From Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (J.S.); Service de Cardiologue du CHU de Nantes, CHU de Nantes, Hôpital Nord, Nantes, France (V.P.); Molecular Cardiology, IRCCS Fondazione Salvatore Maugeri, Pavia, Italy (A.M., C.N., S.G.P.); Dipartimento di Medicina, Molecolare Università di Pavia, Pavia, Italy (S.G.P.); Division of Cardiology, Casa di Cura Pederzoli, Peschiera del Garda, Verona, Italy (P.D.); Arrhythmia Unit, Cardiovascular Surgery and Cardiology Institute, Havana, Cuba (J.C.H.); Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan (K.O., I.W.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy (A.Z., D.C.); Institut Universitaire de Cardiologie et Pneumologie de Québec, Quebec City, QC, Canada (J.C., I.N.); Department of Electrophysiology and Pacing, Onassis Cardiac Surgery Center, Athens, Greece (A.K., G.T.); Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y.); Cardiovascular Research Center and Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston (D.J.M., P.T.E., S.A.L.); Heart Centre AMC, Department of Clinical and Experimental Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (A.W.); Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders, Jeddah, Kingdom of Saudi Arabia (A.W.); Bordeaux University Hospital, LIRYC Institute/INSERM 1045, Bordeaux, France (F.S.); First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany (M.B.); DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany (M.B.); Program in Medical and Population Genetics, Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Department of Cardiology, General Hospital of Conegliano, Conegliano, Treviso, Italy (G.A.); and Lankenau I

Background: The role of programmed ventricular stimulation in identifying patients with Brugada syndrome at the highest risk for sudden death is uncertain.

Methods And Results: We performed a systematic review and pooled analysis of prospective, observational studies of patients with Brugada syndrome without a history of sudden cardiac arrest who underwent programmed ventricular stimulation. We estimated incidence rates and relative hazards of cardiac arrest or implantable cardioverter-defibrillator shock. We analyzed individual-level data from 8 studies comprising 1312 patients who experienced 65 cardiac events (median follow-up, 38.3 months). A total of 527 patients were induced into arrhythmias with up to triple extrastimuli. Induction was associated with cardiac events during follow-up (hazard ratio, 2.66; 95% confidence interval [CI], 1.44-4.92, P<0.001), with the greatest risk observed among those induced with single or double extrastimuli. Annual event rates varied substantially by syncope history, presence of spontaneous type 1 ECG pattern, and arrhythmia induction. The lowest risk occurred in individuals without syncope and with drug-induced type 1 patterns (0.23%, 95% CI, 0.05-0.68 for no induced arrhythmia with up to double extrastimuli; 0.45%, 95% CI, 0.01-2.49 for induced arrhythmia), and the highest risk occurred in individuals with syncope and spontaneous type 1 patterns (2.55%, 95% CI, 1.58-3.89 for no induced arrhythmia; 5.60%, 95% CI, 2.98-9.58 for induced arrhythmia).

Conclusions: In patients with Brugada syndrome, arrhythmias induced with programmed ventricular stimulation are associated with future ventricular arrhythmia risk. Induction with fewer extrastimuli is associated with higher risk. However, clinical risk factors are important determinants of arrhythmia risk, and lack of induction does not necessarily portend low ventricular arrhythmia risk, particularly in patients with high-risk clinical features.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.115.017885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4758872PMC
February 2016

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sudden cardiac death and obesity.

Expert Rev Cardiovasc Ther 2014 Sep;12(9):1099-110

Department of Medicine, Faculty of Medicine, Quebec City, QC, Canada.

For individuals and the society as a whole, the increased risk of sudden cardiac death in obese patients is becoming a major challenge, especially since obesity prevalence has been increasing steadily around the globe. Traditional risk factors and obesity often coexist. Hypertension, diabetes, obstructive sleep apnea and metabolic syndrome are well-known risk factors for CV disease and are often present in the obese patient. Although the bulk of evidence is circumstantial, sudden cardiac death and obesity share common traditional CV risk factors. Structural, functional and metabolic factors modulate and influence the risk of sudden cardiac death in the obese population. Other risk factors such as left ventricular hypertrophy, increased number of premature ventricular complexes, altered QT interval and reduced heart rate variability are all documented in both obese and sudden cardiac death populations. The present review focuses on out-of-hospital sudden cardiac death and potential mechanisms leading to sudden cardiac death in this population.
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http://dx.doi.org/10.1586/14779072.2014.952283DOI Listing
September 2014

Endocardial ablation to eliminate epicardial arrhythmia substrate in scar-related ventricular tachycardia.

J Am Coll Cardiol 2014 Apr 30;63(14):1416-26. Epub 2014 Jan 30.

Department of Cardiac Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Université Victor Segalen Bordeaux II, Institut LYRIC, Equipex MUSIC, Bordeaux, France.

Objectives: We evaluated the feasibility and safety of epicardial substrate elimination with endocardial radiofrequency (RF) delivery in patients with scar-related ventricular tachycardia (VT).

Background: Epicardial RF delivery is limited by fat or associated with bleeding, extra-cardiac damages, coronary vessels and phrenic nerve injury. Alternative ablation approaches might be desirable.

Methods: Forty-six patients (18 ischemic cardiomyopathy [ICM], 13 nonischemic dilated cardiomyopathy [NICM], 15 arrhythmogenic right ventricular cardiomyopathy [ARVC]) with sustained VT underwent combined endo- and epicardial mapping. All patients received endocardial ablation targeting local abnormal ventricular activities in the endocardium (Endo-LAVA) and epicardium (Epi-LAVA), followed by epicardial ablation if needed.

Results: From a total of 173 endocardial ablations targeting Epi-LAVA at the facing site, 48 (28%) applications (ICM: 20 of 71 [28%], NICM: 3 of 39 [8%], ARVC: 25 of 63 [40%]) successfully eliminated the Epi-LAVA. Presence of Endo-LAVA, the most delayed and low bipolar amplitude of Epi-LAVA, low unipolar amplitude in the facing endocardium, and Epi-LAVA within a wall thinning area at computed tomography scan were associated with successful ablation. Endocardial ablation could abolish all Epi-LAVA in 4 ICM and 2 ARVC patients, whereas all patients with NICM required epicardial ablation. Endocardial ablation was able to eliminate Epi-LAVA at least partially in 15 (83%) ICM, 2 (13%) NICM, and 11 (73%) ARVC patients, contributing to a potential reduction in epicardial RF applications. Pericardial bleeding occurred in 4 patients with epicardial ablation.

Conclusions: Elimination of Epi-LAVA with endocardial RF delivery is feasible and might be used first to reduce the risk of epicardial ablation.
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http://dx.doi.org/10.1016/j.jacc.2013.10.087DOI Listing
April 2014