Publications by authors named "Paul Khairy"

389 Publications

Prevalence and Outcome of Early Recurrence of Atrial Tachyarrhythmias in the Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation (CIRCA-DOSE) Study.

Heart Rhythm 2021 Jun 11. Epub 2021 Jun 11.

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

Background: Early recurrence of atrial tachyarrhythmia (ERAT) is common after pulmonary vein isolation (PVI) and has been associated with an increased risk of late AF recurrence.

Objective: We sought to determine the incidence and outcomes of patients experiencing ERAT after PVI using advanced-generation ablation technologies.

Methods: This is a prespecified substudy of the CIRCA-DOSE trial, a prospective, randomized, multicenter study comparing PVI with contact force-guided radiofrequency ablation to secondary-generation cryoballoon ablation for paroxysmal AF. All study patients received an implantable cardiac monitor to allow continuous rhythm monitoring. ERAT was defined as any recurrent atrial tachyarrhythmia within the first 90 days after AF ablation.

Results: ERAT occurred in 61% of the 346 patients at a median of 12 days (range 1-90 days) after ablation. ERAF was a significant predictor of late recurrence (60.1% with ER vs 25.9% without ER;p<0.001) and symptomatic atrial tachyarrhythmia (31.6% with ERAF vs. 6.7% without ERAF;p<0.001). Receiver operating curve analyses revealed a strong correlation between ERAF timing and burden and late recurrence. Multivariate analysis identified ER timing (HR 2.90; 95%CI1.41-5.95;p=0.004) and burden (HR 1.05 per 1% ER burden, 95%CI1.04-1.07;p<0.001) as strong independent predictors of late recurrence. The incidence rate, timing, burden, and prognostic significance of ER did not differ between the study groups.

Conclusions: Early recurrence of atrial tachyarrhythmia remains common after PVI despite use of advanced-generation ablation technologies. Early AF recurrence beyond 3 weeks after ablation is associated with increased risk of late recurrence.
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http://dx.doi.org/10.1016/j.hrthm.2021.06.1172DOI Listing
June 2021

The Role of Ablation in Prevention of Recurrent Implantable Cardioverter Defibrillator Shocks in Patients With Tetralogy of Fallot.

CJC Open 2021 May 28;3(5):619-626. Epub 2021 Jan 28.

University Health Network Toronto, Peter Munk Cardiac Centre, and University of Toronto, Toronto, Ontario, Canada.

Background: Implantable cardioverter defibrillators (ICDs) are effective in preventing arrhythmic sudden cardiac death in patients with tetralogy of Fallot (TOF). Although ICD therapies for malignant ventricular arrhythmias can be life-saving, shocks could have deleterious consequences. Substrate-based ablation therapy has become the standard of care to prevent recurrent ICD shocks in patients with ischemic cardiomyopathy. However, the efficacy and safety of this invasive therapy in the prevention of recurrent ICD shocks in patients with TOF has not been well evaluated.

Methods: Records of a total of 47 consecutive TOF patients (mean age: 43.1 ± 13.2 years, male sex: n = 34 [72.3%]) who underwent ICD implantation for secondary prevention between 2000 and 2018 were reviewed.

Results: Twenty (42.6%) patients underwent invasive therapy (radiofrequency catheter ablation, n = 8; surgical ablation with pulmonary valve replacement, n = 12) before ICD implantation. Twenty-seven patients (57.4%) were managed noninvasively. During follow-up (median 80.5 [interquartile range, 28.5-131.0] months), 2 (10.0%) patients in the invasive group and 10 (37.0%) patients in the noninvasive group received appropriate ICD shocks ( = 0.036). Logistic regression analysis showed that invasive therapy was associated with a decreased risk of ICD shocks by 81.1% (odds ratio, 0.189; 95% confidence interval, 0.036-0.990;  = 0.049). Furthermore, invasive therapy was associated with decreased risk of the composite outcomes of ICD shock, death, cardiac transplantation, and hospital admission (odds ratio, 0.090; 95% confidence interval, 0.025-0.365;  = 0.013) compared with noninvasive therapy.

Conclusions: Invasive substrate modification therapy was associated with a lower likelihood of ICD shocks and improvement of long-term outcomes in TOF patients.
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http://dx.doi.org/10.1016/j.cjco.2021.01.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8134918PMC
May 2021

Lifespan Perspective on Congenital Heart Disease Research: JACC State-of-the-Art Review.

J Am Coll Cardiol 2021 May;77(17):2219-2235

McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit), Department of Medicine, McGill University, Montréal, Québec, Canada. Electronic address:

More than 90% of patients with congenital heart disease (CHD) are nowadays surviving to adulthood and adults account for over two-thirds of the contemporary CHD population in Western countries. Although outcomes are improved, surgery does not cure CHD. Decades of longitudinal observational data are currently motivating a paradigm shift toward a lifespan perspective and proactive approach to CHD care. The aim of this review is to operationalize these emerging concepts by presenting new constructs in CHD research. These concepts include long-term trajectories and a life course epidemiology framework. Focusing on a precision health, we propose to integrate our current knowledge on the genome, phenome, and environome across the CHD lifespan. We also summarize the potential of technology, especially machine learning, to facilitate longitudinal research by embracing big data and multicenter lifelong data collection.
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http://dx.doi.org/10.1016/j.jacc.2021.03.012DOI Listing
May 2021

Autonomic Alterations After Pulmonary Vein Isolation in the CIRCA-DOSE (Cryoballoon vs Irrigated Radiofrequency Catheter Ablation) Study.

J Am Heart Assoc 2021 Feb 26;10(5):e018610. Epub 2021 Feb 26.

Center for Cardiovascular Innovation Vancouver Canada.

Background The natural history of autonomic alterations following catheter ablation of drug-refractory paroxysmal atrial fibrillation is poorly defined, largely because of the historical reliance on non-invasive intermittent rhythm monitoring for outcome ascertainment. Methods and Results The study included 346 patients with drug-refractory paroxysmal atrial fibrillation undergoing pulmonary vein isolation using contemporary advanced-generation ablation technologies. All patients underwent insertion of a Reveal LINQ (Medtronic) implantable cardiac monitor before ablation. The implantable cardiac monitor continuously recorded physical activity, heart rate variability (measured as the SD of the average normal-to-normal), daytime heart rate, and nighttime heart rate. Longitudinal autonomic data in the 2-month period leading up to the date of ablation were compared with the period from 91 to 365 days following ablation. Following ablation there was a significant decrease in SD of the average normal-to-normal (mean difference versus baseline of 19.3 ms; range, 12.9-25.7; <0.0001), and significant increases in daytime and nighttime heart rates (mean difference versus baseline of 9.6 bpm; range, 7.4-11.8; <0.0001, and 7.4 bpm; range, 5.4-9.3; <0.0001, respectively). Patients free of arrhythmia recurrence had significantly faster daytime (11±11 versus 8±12 bpm, =0.001) and nighttime heart rates (8±9 versus 6±8 bpm, =0.049), but no difference in SD of the average normal-to-normal (=0.09) compared with those with atrial fibrillation recurrence. Ablation technology and cryoablation duration did not influence these autonomic nervous system effects. Conclusions Pulmonary vein isolation results in significant sustained changes in the heart rate parameters related to autonomic function. These changes are correlated with procedural outcome and are independent of the ablation technology used. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01913522.
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http://dx.doi.org/10.1161/JAHA.120.018610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174287PMC
February 2021

Preventing Arrhythmic Death in Patients With Tetralogy of Fallot: JACC Review Topic of the Week.

J Am Coll Cardiol 2021 Feb;77(6):761-771

Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.

Patients with tetralogy of Fallot are at risk for ventricular arrhythmias and sudden cardiac death. These abnormalities are associated with pulmonary regurgitation, right ventricular enlargement, and a substrate of discrete, slowly-conducting isthmuses. Although these arrhythmic events are rare, their prediction is challenging. This review will address contemporary risk assessment and prevention strategies. Numerous variables have been proposed to predict who would benefit from an implantable cardioverter-defibrillator. Current risk stratification models combine independently associated factors into risk scores. Cardiac magnetic resonance imaging, QRS fragmentation assessment, and electrophysiology testing in selected patients may refine some of these models. Interaction between right and left ventricular function is emerging as a critical factor in our understanding of disease progression and risk assessment. Multicenter studies evaluating risk factors and risk mitigating strategies such as pulmonary valve replacement, ablative strategies, and use of implantable cardiac-defibrillators are needed moving forward.
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http://dx.doi.org/10.1016/j.jacc.2020.12.021DOI Listing
February 2021

Phenotypes of adults with congenital heart disease around the globe: a cluster analysis.

Health Qual Life Outcomes 2021 Feb 10;19(1):53. Epub 2021 Feb 10.

KU Leuven Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, Box 7001, 3000, Leuven, Belgium.

Objective: To derive cluster analysis-based groupings for adults with congenital heart disease (ACHD) when it comes to perceived health, psychological functioning, health behaviours and quality of life (QoL).

Methods: This study was part of a larger worldwide multicentre study called APPROACH-IS; a cross sectional study which recruited 4028 patients (2013-2015) from 15 participating countries. A hierarchical cluster analysis was performed using Ward's method in order to group patients with similar psychological characteristics, which were defined by taking into consideration the scores of the following tests: Sense Of Coherence, Health Behavior Scale (physical exercise score), Hospital Anxiety Depression Scale, Illness Perception Questionnaire, Satisfaction with Life Scale and the Visual Analogue Scale scores of the EQ-5D perceived health scale and a linear analogue scale (0-100) measuring QoL.

Results: 3768 patients with complete data were divided into 3 clusters. The first and second clusters represented 89.6% of patients in the analysis who reported a good health perception, QoL, psychological functioning and the greatest amount of exercise. Patients in the third cluster reported substantially lower scores in all PROs. This cluster was characterised by a significantly higher proportion of females, a higher average age the lowest education level, more complex forms of congenital heart disease and more medical comorbidities.

Conclusions: This study suggests that certain demographic and clinical characteristics may be linked to less favourable health perception, quality of life, psychological functioning, and health behaviours in ACHD. This information may be used to improve psychosocial screening and the timely provision of psychosocial care.
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http://dx.doi.org/10.1186/s12955-021-01696-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877115PMC
February 2021

Pathophysiology, Risk Factors, and Management of Atrial Fibrillation in Adult Congenital Heart Disease.

Card Electrophysiol Clin 2021 03 8;13(1):191-199. Epub 2021 Jan 8.

Electrophysiology Service and Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada. Electronic address:

A confluence of clinical and epidemiologic factors has provoked a steep increase in the prevalence of atrial fibrillation in adults with congenital heart disease. Atrial fibrillation is the most common presenting arrhythmia. Much remains to be unraveled about the mitigating role congenital heart disease, residual hemodynamic defects, surgical ramifications, and shunts and cyanosis on new-onset and recurrent atrial fibrillation in this population. Catheter ablation is increasingly performed for atrial fibrillation. This synopsis provides an overview of current knowledge on atrial fibrillation in adults with congenital heart disease, addresses clinical management, and discusses knowledge gaps and areas for future research.
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http://dx.doi.org/10.1016/j.ccep.2020.10.007DOI Listing
March 2021

Patient-Reported Outcomes in Adults With Congenital Heart Disease Following Hospitalization (from APPROACH-IS).

Am J Cardiol 2021 04 15;145:135-142. Epub 2021 Jan 15.

Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Canada; Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon.

In this international study, we (1) compared patient-reported outcomes (PROs) in adults with congenital heart disease (CHD) who had versus had not been hospitalized during the previous 12 month, (2) contrasted PROs in patients who had been hospitalized for cardiac surgery versus nonsurgical reasons, (3) assessed the magnitude of differences between the groups (i.e., effect sizes), and (4) explored differential effect sizes between countries. APPROACH-IS was a cross-sectional, observational study that enrolled 4,028 patients from 15 countries (median age 32 years; 53% females). Self-report questionnaires were administered to measure PROs: health status; anxiety and depression; and quality of life. Overall, 668 patients (17%) had been hospitalized in the previous 12 months. These patients reported poorer outcomes on all PROs, with the exception of anxiety. Patients who underwent cardiac surgery demonstrated a better quality of life compared with those who were hospitalized for nonsurgical reasons. For significant differences, the effect sizes were small, whereas they were negligible in nonsignificant comparisons. Substantial intercountry differences were observed. For various PROs, moderate to large effect sizes were found comparing different countries. In conclusion, adults with CHD who had undergone hospitalization in the previous year had poorer PROs than those who were medically stable. Researchers ought to account for the timing of recruitment when conducting PRO research as hospitalization can impact results.
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http://dx.doi.org/10.1016/j.amjcard.2020.12.088DOI Listing
April 2021

Sudden Cardiac Death Prediction in Arrhythmogenic Right Ventricular Cardiomyopathy: A Multinational Collaboration.

Circ Arrhythm Electrophysiol 2021 01 9;14(1):e008509. Epub 2020 Dec 9.

Department of Medicine, Division of Cardiology (J.C.-T., W.W., A.B., C.T., B.M., S.C., J.E.C., D.P.J., H.T., H.C., C.A.J.), Johns Hopkins Hospital, Baltimore, MD.

Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is associated with ventricular arrhythmias (VA) and sudden cardiac death (SCD). A model was recently developed to predict incident sustained VA in patients with ARVC. However, since this outcome may overestimate the risk for SCD, we aimed to specifically predict life-threatening VA (LTVA) as a closer surrogate for SCD.

Methods: We assembled a retrospective cohort of definite ARVC cases from 15 centers in North America and Europe. Association of 8 prespecified clinical predictors with LTVA (SCD, aborted SCD, sustained, or implantable cardioverter-defibrillator treated ventricular tachycardia >250 beats per minute) in follow-up was assessed by Cox regression with backward selection. Candidate variables included age, sex, prior sustained VA (≥30s, hemodynamically unstable, or implantable cardioverter-defibrillator treated ventricular tachycardia; or aborted SCD), syncope, 24-hour premature ventricular complexes count, the number of anterior and inferior leads with T-wave inversion, left and right ventricular ejection fraction. The resulting model was internally validated using bootstrapping.

Results: A total of 864 patients with definite ARVC (40±16 years; 53% male) were included. Over 5.75 years (interquartile range, 2.77-10.58) of follow-up, 93 (10.8%) patients experienced LTVA including 15 with SCD/aborted SCD (1.7%). Of the 8 prespecified clinical predictors, only 4 (younger age, male sex, premature ventricular complex count, and number of leads with T-wave inversion) were associated with LTVA. Notably, prior sustained VA did not predict subsequent LTVA (=0.850). A model including only these 4 predictors had an optimism-corrected C-index of 0.74 (95% CI, 0.69-0.80) and calibration slope of 0.95 (95% CI, 0.94-0.98) indicating minimal over-optimism.

Conclusions: LTVA events in patients with ARVC can be predicted by a novel simple prediction model using only 4 clinical predictors. Prior sustained VA and the extent of functional heart disease are not associated with subsequent LTVA events.
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http://dx.doi.org/10.1161/CIRCEP.120.008509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834666PMC
January 2021

Impact of Catheter Ablation for Atrial Arrhythmias on Repeat Cardioversion in Adults With Congenital Heart Disease.

Can J Cardiol 2020 Nov 24. Epub 2020 Nov 24.

Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network Toronto and University of Toronto, Toronto, Ontario, Canada. Electronic address:

Background: Atrial tachyarrhythmias (AAs) are the main source of morbidity and mortality in adult congenital heart disease (ACHD). Direct-current cardioversion (DCCV) is an effective method to acutely terminate AAs, but many patients require repeated DCCV. Little is known about the impact of radiofrequency catheter ablation (RFCA) of AAs on the incidence of repeated DCCV in patients with ACHD. The purpose of this study was to evaluate the impact of RFCA on the incidence of DCCV in patients with ACHD.

Methods: A total of 157 patients with ACHD undergoing DCCV in our hospital from 2011 to 2018 (female n = 76 [48.4%], mean age 37.8 ± 12.5 y), were reviewed. The median follow-up period was 31.8 months (interquartile range 16.3-55.1 mo).

Results: Out of the total of 157 patients, 102 (65.0%) underwent RFCA for AAs, and 55 (35.0%) were treated without RFCA. Successful RFCA with termination of AAs during ablation was 62.7%. More than one-half of the patients had complex forms of CHD (62.4%). During follow-up, 57 patients (55.9%) who had RFCA developed recurrence of AAs, and 36 patients (35.2%) underwent repeated DCCV. Thirty-three (60.0%) out of 55 patients without RFCA required repeated cardioversion. Compared with patients without RFCA, RFCA significantly reduced the need for repeated DCCV by 40% (hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.23-0.80; P = 0.009). In multivariate analysis, successful RFCA was associated with reduced risk of DCCV (HR 0.41, 95% CI 0.19-0.92; P = 0.031).

Conclusions: AAs remain common despite RFCA in patients with ACHD. Nevertheless, RFCA is associated with a marked reduction in the need for repeated DCCV.
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http://dx.doi.org/10.1016/j.cjca.2020.11.006DOI Listing
November 2020

The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation.

Can J Cardiol 2020 12 22;36(12):1847-1948. Epub 2020 Oct 22.

Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.

The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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http://dx.doi.org/10.1016/j.cjca.2020.09.001DOI Listing
December 2020

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

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

Montreal Health Innovations Coordinating Center (MHICC), Montreal, Quebec, Canada.

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

New developments in catheter ablation for patients with congenital heart disease.

Expert Rev Cardiovasc Ther 2021 Jan 13;19(1):15-26. Epub 2020 Nov 13.

Montreal Heart Institute, Université De Montréal , Montreal, Canada.

: There are numerous challenges to catheter ablation in patients with congenital heart disease (CHD), including access to cardiac chambers, distorted anatomies, displaced conduction systems, multiple and/or complex arrhythmia substrates, and excessively thickened walls, or interposed material. : Herein, we review recent developments in catheter ablation strategies for patients with CHD that are helpful in addressing these challenges. : Remote magnetic navigation overcomes many challenges associated with vascular obstructions, chamber access, and catheter contact. Patients with CHD may benefit from a range of ablation catheter technologies, including irrigated-tip and contact-force radiofrequency ablation and focal and balloon cryoablation. High-density mapping, along with advances in multipolar catheters and interpolation algorithms, is contributing to new mechanistic insights into complex arrhythmias. Ripple mapping allows the activation wave front to be tracked visually without prior assignment of local activation times or window of interest, and without interpolations of unmapped regions. There is growing interest in measuring conduction velocities to identify arrhythmogenic substrates. Noninvasive mapping with a multielectrode-embedded vest allows prolonged bedside monitoring, which is of particular interest in those with non-sustained or multiple arrhythmias. Further studies are required to assess the role of radiofrequency needle catheters and stereotactic radiotherapy in patients with CHD.
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http://dx.doi.org/10.1080/14779072.2021.1847082DOI Listing
January 2021

Role of amiodarone in the management of atrial arrhythmias in adult Fontan patients.

Heart 2020 Oct 28. Epub 2020 Oct 28.

Electrophysiology department, Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada

Background: Patients with Fontan circulation are known to be at high risk for developing atrial tachyarrhythmias (AAs). Our objective was to examine the efficacy and safety of amiodarone in the management of ATs in adult Fontan patients.

Methods: Primary outcomes of this single-centre, retrospective study included freedom from AAs and incidence of adverse effects of amiodarone on Fontan patients. Heart failure (HF) events and composite outcomes of death from any cause, Fontan revision and heart transplantation were evaluated as secondary outcomes. Predictors of HF and discontinuing amiodarone were also evaluated.

Results: A total of 61 patients (mean age 31.6±11.3 years, 40.9% female), who were treated with amiodarone in between 1995 and 2018, were included. AAs free survival at 1, 3 and 5 years were 76.2%, 56.9% and 30.6%, respectively. During a median follow-up of 50.5 months, 34 (55.7%) patients developed side effects, and 20 (32.8%) patients discontinued amiodarone due to side effects. Thyroid dysfunction was the most common side effect (n=26, 76.5%), amiodarone-induced thyrotoxicosis (AIT) (n=16, 27.1%) being most common thyroid dysfunction. Young age (age <28.5 years) was associated with discontinuing amiodarone (HR 5.50, 95% CI 1.19 to 25.4, p=0.029). AIT significantly increased risk of HF (HR 4.82, 95% CI 1.71 to 13.6, p=0.003).

Conclusions: Short-term efficacy of amiodarone in Fontan physiology is acceptable. However, long-term administration is associated with a reduction of efficacy and a significant prevalence of non-cardiac side effects. AIT is associated with exacerbation of HF. The judicious use of amiodarone administration should be considered in this population.
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http://dx.doi.org/10.1136/heartjnl-2020-317378DOI Listing
October 2020

Colchicine for Secondary Prevention of Cardiovascular Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Can J Cardiol 2021 May 17;37(5):776-785. Epub 2020 Oct 17.

Montreal Health Innovations Coordinating Center, Montréal, Québec, Canada.

Background: Reduction of inflammation with colchicine has emerged as a therapeutic option for secondary prevention of cardiovascular disease (CVD) in patients with coronary artery disease (CAD). Our objective was to consolidate evidence from randomized controlled trials (RCTs) evaluating the efficacy and safety of low-dose colchicine for secondary prevention of CVD among patients with CAD on standard medical therapy.

Methods: RCTs comparing the incidence of cardiovascular (CV) events between patients with clinically manifest CAD randomized to colchicine vs placebo (or no colchicine) were included. The primary composite efficacy endpoint included CV mortality, myocardial infarction (MI), ischemic stroke, and urgent coronary revascularization. The DerSimonian and Laird random-effects model was used to calculate pooled hazard ratios (HRs) and 95% confidence intervals (CIs).

Results: Four RCTs, with a pooled sample size of 11,594 patients, were included (colchicine n = 5774; placebo/no colchicine n = 5820). Included RCTs studied populations with stable CAD (N = 2) and acute coronary syndrome (N = 2). Compared with placebo or no colchicine, colchicine was associated with a statistically significant reduction in the incidence of the primary composite endpoint (pooled HR, 0.68; 95% CI, 0.54-0.81; I = 37.7%). The reduction in CV events among patients randomized to colchicine was driven by statistically significant reductions in MIs, ischemic strokes, and urgent coronary revascularizations (P < 0.05 for all) and was relatively consistent among subgroups. The incidence of safety outcomes did not differ between groups (P > 0.05).

Conclusions: In secondary prevention of CV events, the addition of low-dose colchicine to standard medical therapy reduces the incidence of major CV events-except CV mortality-when compared with standard medical therapy alone.
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http://dx.doi.org/10.1016/j.cjca.2020.10.006DOI Listing
May 2021

Veno-Venous Extracorporeal Membrane Oxygenation to Treat Acute Respiratory Distress Syndrome in an Adult with Fontan Palliation.

ASAIO J 2020 Oct 15. Epub 2020 Oct 15.

From the Department of Cardiac Intensive Care.

In patients with Fontan palliation, the systemic and pulmonary circulation is in series and supported by a single ventricle, resulting in fragile hemodynamics. Cardiac output is driven by low pressure nonpulsatile pulmonary flow and is highly dependent on pulmonary vascular resistance. An acute respiratory distress syndrome (ARDS) can rapidly alter this physiology and lead to severe cardiogenic shock. Herein, we describe the case of a 40 year old man with a classic modified Fontan procedure and bidirectional Glenn shunt who developed ARDS with cardiogenic shock following a resuscitated cardiac arrest with presumed aspiration pneumonia. In light of poorly tolerated positive end-expiratory pressure ventilation and underlying anatomical complexities, a multidisciplinary team was convened to optimize care. In part owing to the lack of femoral venous access, a veno-venous extracorporeal membrane oxygenation circuit was devised using bilateral internal jugular venous access. Under fluoroscopic guidance in a hybrid operating room, one cannula was placed in the inferior vena cava by means of the right internal jugular venous access, with the second cannula positioned in the right pulmonary artery through the left internal jugular vein. Oxygenation and hemodynamic status promptly improved, allowing the patient to recover from ARDS.
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http://dx.doi.org/10.1097/MAT.0000000000001293DOI Listing
October 2020

Changes in outcomes over time in intermediate-risk patients treated for severe aortic stenosis.

J Card Surg 2020 Dec 5;35(12):3422-3429. Epub 2020 Oct 5.

Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada.

Background: The advent of transcatheter aortic valve replacement (TAVR) has changed the practice of treating patients with severe aortic stenosis (AS). Heart-Teams have improved their decision-making process to refer patients to the best and safest treatment. The evidence allowed centers to increase funding and TAVR volume and extend indications to different risk categories of patients. This study evaluates the outcomes of intermediate-risk patients treated for severe AS in an academic center.

Methods: Between 2012 and 2019, 812 patients with AS underwent TAVR or surgical aortic valve replacement (SAVR). A propensity score-matching analytic strategy was used to balance groups and adjust for time periods. Outcomes were recorded according to the Society of Thoracic Surgeons Guidelines; the primary outcome being 30-day mortality and the secondary outcomes being perioperative course and complications.

Results: No difference in mortality was seen but complications differed: more postoperative transient ischemic attacks, permanent pacemaker implantations, and perivalvular leaks in the transcatheter group, while more acute kidney injuries, atrial fibrillation, delirium, postoperative infections and bleeding, tamponade and need for reoperation in the surgical group as well as a longer hospital length-of-stay. However, over the years, morbidities/mortality decreased for all patients treated for AS.

Conclusions: Data showed an improvement in morbidities/mortality for intermediate-risk patients treated with SAVR or TAVR. Increased funding allowed for a higher TAVR volume by increasing access to this technology. Also, the difference in complications could impact healthcare costs. By incorporating important metrics such as length-of-stay, readmission rates, and complications into decision-making, the Heart-Team can improve clinical outcomes, healthcare economics, and resource utilization.
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http://dx.doi.org/10.1111/jocs.15063DOI Listing
December 2020

Infections Associated with Resterilized Pacemakers and Defibrillators. Reply.

Authors:
Paul Khairy

N Engl J Med 2020 10;383(14):1397

Montreal Heart Institute, Montreal, QC, Canada

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http://dx.doi.org/10.1056/NEJMc2027519DOI Listing
October 2020

Distorting Effect of Immortal Time Bias on the Association Between Catheter Ablation for Atrial Fibrillation and Incident Stroke: Caveat Emptor.

Can J Cardiol 2021 03 24;37(3):377-381. Epub 2020 Sep 24.

Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada. Electronic address:

We assessed the presence of immortal time bias (ITB) in observational studies evaluating the effectiveness of radiofrequency catheter ablation for atrial fibrillation (AF) on reduction of stroke. Eligible studies were classified based on presence or absence of ITB. Hazard ratios (HRs) were pooled using the random-effects model. Eight of 10 (80%) studies were subject to ITB. Pooling studies without ITB indicated no statistically significant reduction in incident strokes (HR 0.75; 95% confidence interval [CI], 0.49-1.02]. In conclusion, the pervasiveness of ITB in observational studies precludes definitive conclusions regarding an effect of AF ablation on strokes. Further studies designed to avoid ITB are warranted.
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http://dx.doi.org/10.1016/j.cjca.2020.09.010DOI Listing
March 2021

Atrial arrhythmias and patient-reported outcomes in adults with congenital heart disease: An international study.

Heart Rhythm 2021 May 19;18(5):793-800. Epub 2020 Sep 19.

Montreal Heart Institute, Université de Montréal, Montreal, Canada.

Background: Atrial arrhythmias (ie, intra-atrial reentrant tachycardia and atrial fibrillation) are a leading cause of morbidity and hospitalization in adults with congenital heart disease (CHD). Little is known about their effect on quality of life and other patient-reported outcomes (PROs) in adults with CHD.

Objective: The purpose of this study was to assess the impact of atrial arrhythmias on PROs in adults with CHD and explore geographic variations.

Methods: Associations between atrial arrhythmias and PROs were assessed in a cross-sectional study of adults with CHD from 15 countries spanning 5 continents. A propensity-based matching weight analysis was performed to compare quality of life, perceived health status, psychological distress, sense of coherence, and illness perception in patients with and those without atrial arrhythmias.

Results: A total of 4028 adults with CHD were enrolled, 707 (17.6%) of whom had atrial arrhythmias. After applying matching weights, patients with and those without atrial arrhythmias were comparable with regard to age (mean 40.1 vs 40.2 years), demographic variables (52.5% vs 52.2% women), and complexity of CHD (15.9% simple, 44.8% moderate, and 39.2% complex in both groups). Patients with atrial arrhythmias had significantly worse PRO scores with respect to quality of life, perceived health status, psychological distress (ie, depression), and illness perception. A summary score that combines all PRO measures was significantly lower in patients with atrial arrhythmias (-3.3%; P = .0006). Differences in PROs were consistent across geographic regions.

Conclusion: Atrial arrhythmias in adults with CHD are associated with an adverse impact on a broad range of PROs consistently across various geographic regions.
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http://dx.doi.org/10.1016/j.hrthm.2020.09.012DOI Listing
May 2021

Understanding Electrocardiography in Adult Patients With Congenital Heart Disease: A Review.

JAMA Cardiol 2020 12;5(12):1435-1444

Cardiac Electrophysiology Section, European Georges Pompidou Hospital, Paris, France.

Importance: Congenital heart disease in adults is still a relatively new concept for many cardiologists, and the complexity as well as diversity of cardiac phenotypes encountered necessitate that systematic, practical information be available for the nonspecialist. The analysis of the 12-lead electrocardiogram is an invaluable cornerstone in the clinical appraisal of these patients.

Observations: Consideration of the main anatomic and pathophysiological aspects of the various congenital heart conditions can shed light on their distinctive electrocardiogram patterns, which are an electrical reflection of intrinsic cardiac anatomy abnormalities, surgical scarring, and progressive cardiac remodeling attributable to hemodynamic perturbations. While congenital heart disease may be diagnosed or suspected on electrocardiogram observation in adults who are previously undiagnosed, specific markers have also been identified to optimize risk stratification in certain defects.

Conclusions And Relevance: This review outlines that main electrocardiogram patterns in adult patients with congenital heart disease can be appreciated by the understanding of the underlying pathophysiology. Periodic surveillance is of particular importance in this population to unmask early electric signs of disease evolution.
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http://dx.doi.org/10.1001/jamacardio.2020.3416DOI Listing
December 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

Quality of Life and Health Care Utilization in the CIRCA-DOSE Study.

JACC Clin Electrophysiol 2020 08;6(8):935-944

Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada; Montreal Health Innovations Coordinating Centre, Montreal, Québec, Canada.

Objectives: This study evaluated the impact of contact force-guided radiofrequency ablation versus cryoballoon ablation on quality of life and health care utilization.

Background: Traditional outcome parameters, such as arrhythmia-free survival, are insufficient to evaluate the clinical impact of atrial fibrillation (AF), as it fails to the capture patient- and health system-level differences in treatment approaches.

Methods: The CIRCA-DOSE (Cryoballoon Vs. Contact-Force Atrial Fibrillation Ablation) study randomly assigned 346 patients with drug-refractory paroxysmal AF to contact force-guided radiofrequency or cryoballoon ablation. Health-related quality-of-life (HRQOL) was assessed at baseline, and at 6 and 12 months post-ablation using a disease-specific and generic HRQOL instruments. Health care utilization (hospitalization, emergency department visits, and cardioversion) and antiarrhythmic drug use for the 12 months preceding ablation was compared with the 12 months following ablation.

Results: Disease-specific and generic HRQOL was moderately to severely impaired at baseline and improved significantly at 6 and 12 months of follow-up (median improvement in AFEQT [Atrial Fibrillation Effect on QualiTy of Life] score 32.4 [interquartile range: 17.7 to 48.9]). When compared with the 12 months pre-ablation, the proportion and absolute number of cardioversions decreased significantly (41.1% vs. 10.1% of patients, 137 vs. 35 events; p < 0.0001). Similar significant reductions in emergency department visits (66.7% vs. 25.1% of patients, 224 vs. 87 events; p < 0.0001), and hospitalizations (25.5% vs. 14.5% of patients, 86 vs. 50 events; p < 0.001) were observed. There were no significant differences between randomized groups.

Conclusions: In this multicenter randomized trial, catheter ablation with advanced-generation technologies resulted in a significant improvement in HRQOL and a significant reduction in health care utilization in the year following AF ablation. (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation [CIRCA-DOSE]; NCT01913522).
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http://dx.doi.org/10.1016/j.jacep.2020.04.017DOI Listing
August 2020

Safety and efficacy of non-vitamin K antagonist oral anticoagulants for prevention of thromboembolism in adults with systemic right ventricle: Results from the NOTE international registry.

Int J Cardiol 2021 01 14;322:129-134. Epub 2020 Aug 14.

Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy.

Background: Patients with systemic right ventricle (sRV), including transposition of great arteries (TGA) after atrial switch procedure and congenitally corrected transposition of great arteries (ccTGA), may require anticoagulation for thromboembolism (TE) prevention. In the absence of data on non-vitamin K antagonist oral anticoagulants (NOACs), vitamin K antagonists (VKAs) remain the agent of choice. We investigated the safety, efficacy and feasibility of NOACs treatment in adults with sRV in a worldwide study.

Methods: This is an international multicentre prospective study, using data from the NOTE registry on adults with sRV taking NOACs between 2014 and 2019. The primary endpoints were TE and major bleeding (MB). The secondary endpoint was minor bleeding.

Results: A total of 76 patients (42.5 ± 10.0 years, 76% male) with sRV (74% TGA, 26% ccTGA) on NOACs were included in the study. During a median follow-up of 2.5 years (IQR1.5-3.9), TE events occurred in 3 patients (4%), while no MB episodes were reported. Minor bleeding occurred in 9 patients (12%). NOAC treatment cessation rate was 1.4% (95%CI:0.3-4%) during the first year of follow-up. All the patients with TE events had a CHADS-VASc score ≥ 2 and impaired sRV systolic function at baseline. The total incidence of major events during follow-up was significantly lower compared to historical use of VKAs or aspirin before study inclusion (1.4% (95%CI:0.29-4%) vs 6,9% (95%CI:2.5-15.2%); p = .01).

Conclusions: In this prospective study, NOACs appear to be well-tolerated, with excellent efficacy and safety at mid-term in patients with sRV.
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http://dx.doi.org/10.1016/j.ijcard.2020.08.034DOI Listing
January 2021

Risk prediction models for heart failure admissions in adults with congenital heart disease.

Int J Cardiol 2021 01 14;322:149-157. Epub 2020 Aug 14.

McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada; iCACH Net Group (Canadian Adult Congenital Heart Disease Network Investigators' Group), Canada. Electronic address:

Background: Heart failure (HF) is the leading cause of death in adult patients with congenital heart disease (ACHD). No risk prediction model exists for HF hospitalization (HFH) for ACHD patients. We aimed to develop a clinically relevant one-year risk prediction system to identify ACHD patients at high risk for HFH.

Methods: Data source was the Quebec CHD Database. A retrospective cohort including all ACHD patients aged 18-64 (1995-2010) was constructed for assessing the cumulative risk of HFH adjusting for competing risk of death. To identify one-year predictors of incident HFH, multivariable logistic regressions were employed to a nested case-control sample of all ACHD patients aged 18-64 in 2009. The final model was used to create a risk score system based on adjusted odds ratios.

Results: The cohort included 29,991 ACHD patients followed for 648,457 person-years. The cumulative HFH risk by age 65 was 12.58%. The case-control sample comprised 26,420 subjects, of whom 189 had HFHs. Significant one-year predictors were age ≥ 50, male sex, CHD lesion severity, recent 12-month HFH history, pulmonary arterial hypertension, chronic kidney disease, coronary artery disease, systemic arterial hypertension, and diabetes mellitus. The created risk score ranged from 0 to 19. The corresponding HFH risk rose rapidly beyond a score of 8. The risk scoring system demonstrated excellent prediction performance.

Conclusions: One eighth of ACHD population experienced HFH before age 65. Age, sex, CHD lesion severity, recent 12-month HFH history, and comorbidities constructed a risk prediction model that successfully identified patients at high risk for HFH.
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http://dx.doi.org/10.1016/j.ijcard.2020.08.039DOI Listing
January 2021

Physical Functioning, Mental Health, and Quality of Life in Different Congenital Heart Defects: Comparative Analysis in 3538 Patients From 15 Countries.

Can J Cardiol 2021 02 6;37(2):215-223. Epub 2020 Apr 6.

Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada; Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA.

Background: We compared physical functioning, mental health, and quality of life (QoL) of patients with different subtypes of congenital heart disease (CHD) in a large international sample and investigated the role of functional class in explaining the variance in outcomes across heart defects.

Methods: In the cross-sectional Assessment of Patterns of Patient-Reported Outcome in Adults with Congenital Heart Disease-International Study (APPROACH-IS), we enrolled 4028 adult patients with CHD from 15 countries. Diagnostic groups with at least 50 patients were included in these analyses, yielding a sample of 3538 patients (median age: 32 years; 52% women). Physical functioning, mental health, and QoL were measured with the SF-12 health status survey, Hospital Anxiety and Depression Scale (HADS), linear analog scale (LAS) and Satisfaction with Life Scale, respectively. Functional class was assessed using the patient-reported New York Heart Association (NYHA) class. Multivariable general linear mixed models were applied to assess the relationship between the type of CHD and patient-reported outcomes, adjusted for patient characteristics, and with country as random effect.

Results: Patients with coarctation of the aorta and those with isolated aortic valve disease reported the best physical functioning, mental health, and QoL. Patients with cyanotic heart disease or Eisenmenger syndrome had worst outcomes. The differences were statistically significant, above and beyond other patient characteristics. However, the explained variances were small (0.6% to 4.1%) and decreased further when functional status was added to the models (0.4% to 0.9%).

Conclusions: Some types of CHD predict worse patient-reported outcomes. However, it appears that it is the functional status associated with the heart defect rather than the heart defect itself that shapes the outcomes.
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http://dx.doi.org/10.1016/j.cjca.2020.03.044DOI Listing
February 2021

Repeat Atrial Fibrillation Ablation Procedures in the CIRCA-DOSE Study.

Circ Arrhythm Electrophysiol 2020 09 23;13(9):e008480. Epub 2020 Jul 23.

Department of Medicine, University of British Columbia, Vancouver, Canada (C.C.C., M.W.D., J.G.A.).

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http://dx.doi.org/10.1161/CIRCEP.120.008480DOI Listing
September 2020

The Cryoballoon vs Irrigated Radiofrequency Catheter Ablation (CIRCA-DOSE) Study Results in Context.

Arrhythm Electrophysiol Rev 2020 Jun;9(1):34-39

Montreal Heart Institute, Department of Medicine, University of Montreal, Montreal, Canada.

The Cryoballoon vs Irrigated Radiofrequency Catheter Ablation: Double Short vs Standard Exposure Duration (CIRCA-DOSE) study was a multicentre, randomised, single-blinded trial that compared contact-force radiofrequency ablation and two different regimens of cryoballoon ablation. All patients received an implantable cardiac monitor for the purpose of continuous rhythm monitoring, with all arrhythmia events undergoing independent adjudication by a committee blinded to treatment allocation. The study demonstrated there were no significant differences between contact-force radiofrequency ablation and cryoballoon ablation with respect to recurrence of any atrial tachyarrhythmia, symptomatic atrial tachyarrhythmia, asymptomatic AF, symptomatic AF or AF burden. While the results of the CIRCA-DOSE study are reviewed here, this article focuses on considerations around the design of the study and places the observed outcomes in context.
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http://dx.doi.org/10.15420/aer.2019.13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330729PMC
June 2020

Impact of Left Common Pulmonary Veins in the Contact-Force vs. Cryoballoon Atrial Fibrillation Ablation (CIRCA-DOSE) Study.

J Cardiovasc Electrophysiol 2020 Jul 6. Epub 2020 Jul 6.

Heart Rhythm Services, Department of Medicine, University of British Columbia, Canada.

Background: Concerns remain regarding the effectiveness of PVI using the fixed diameter non-compliant cryoballoon in the presence of a left common pulmonary vein (LCPV). We sought to evaluate the effectiveness of PVI performed by contact-force guided radiofrequency (CF-RF) versus second-generation cryoballoon-based ablation in patients with LCPV.

Methods And Results: We enrolled 346 patients with paroxysmal AF and randomized them to CF-RF or cryoballoon ablation. PV anatomy was not assessed prior to enrolment, and there were no exclusions based on PV anatomy. All patients received an implantable cardiac monitor. LCPV was observed in 13.6% of patients (47/346). Left atrial time and fluoroscopy time did not differ between those with and without LCPV (P=0.58 and P=0.06, respectively). Freedom from any atrial tachyarrhythmia at one year was observed in 46.8% with LCPV and 54.5% without LCPV (P=0.06). In those with LCPV the freedom from any atrial tachyarrhythmia did not differ between those randomized to CF-RF or cryoballoon ablation (HR for recurrence 1.19, 95% CI 0.53-2.65, P=0.69). In those with LCPV the AF burden was reduced to a similar extent with CF-RF and cryoballoon ablation (99.7% vs. 99.5%, respectively; P=0.97).

Conclusions: In this randomized clinical trial, the presence of a LCPV was associated with a trend towards higher rates of arrhythmia recurrence following PVI. No significant difference in arrhythmia recurrence was observed between patients with LCPV randomized to cryoballoon ablation or contact-force guided RF ablation, suggesting that either ablation modality is suitable in this population. (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation [CIRCA-DOSE], NCT01913522) This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/jce.14652DOI Listing
July 2020

Adults with Congenital Heart Disease and Arrhythmia Management.

Cardiol Clin 2020 Aug 7;38(3):417-434. Epub 2020 Jun 7.

Electrophysiology Service and Adult Congenital Heart Disease Center; Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000 Bélanger Street, Montreal, Quebec H1T 1C8, Canada.

Arrhythmia management in adult congenital heart disease (ACHD) encompasses a wide range of problems from bradyarrhythmia to tachyarrhythmia, sudden death, and heart failure-related electrical dyssynchrony. Major advances in the understanding of the pathophysiology and treatments of these problems over the past decade have resulted in improved therapeutic strategies and outcomes. This article attempts to define these problems and review contemporary management for the patient with ACHD presenting with cardiac arrhythmia.
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http://dx.doi.org/10.1016/j.ccl.2020.04.006DOI Listing
August 2020