Publications by authors named "Philippe Maury"

174 Publications

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

JACC Clin Electrophysiol 2021 Apr 21. Epub 2021 Apr 21.

Auxerre Hospital, Auxerre, France.

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

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

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

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

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

Relationships between left ventricular mass and QRS duration in diverse types of left ventricular hypertrophy.

Eur Heart J Cardiovasc Imaging 2021 Apr 11. Epub 2021 Apr 11.

Department of Cardiology, University Hospital Rangueil, 1 avenue Pr. Jean Poulhès 31400 Toulouse, France.

Aims: Hypertrophic cardiomyopathy (HCM) may be associated with very narrow QRS, while left ventricular hypertrophy (LVH) may increase QRS duration. We investigated the relationships between QRS duration and LV mass (LVM) in subtypes of abnormal LV wall thickness.

Methods And Results: Automated measurement of LVM on MRI was correlated to automated measurement of QRS duration on ECG in HCM, left ventricular non compaction (LVNC), left ventricular hypertrophy (LVH), and controls with healthy hearts. Uni and multivariate analyses were performed between groups including explanatory variables expected to influence LVM and QRS duration. The relationships between QRS duration and LVM were further studied within each group. Two hundred and twenty-one HCM, 28 LVNC, 16 LVH, and 40 controls were retrospectively included. Mean QRS duration was 92 ms for HCM, 104 for LVNC, 110 for LVH, and 92 for controls (P < 0.01). Mean LVM was 100, 90, 108, and 68 g/m2 (P < 0.01). QRS duration, LVM, hypertension, maximal wall thickness, and late gadolinium enhancement were significantly linked to HCM in multivariate analysis (w/wo bundle branch block). An independent negative correlation was found between LVM and QRS duration in the HCM group, while the relationship was reverse in LVNC, LVH, and controls.

Conclusion: QRS duration increases with LVM in LVNC, LVH, or in healthy hearts, while reverse relationship is present in HCM. These relationships were independent from other parameters. These results warrant additional investigations for refining diagnosis criteria for HCM in the future.
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http://dx.doi.org/10.1093/ehjci/jeab063DOI Listing
April 2021

Focus on stereotactic radiotherapy: A new way to treat severe ventricular arrhythmias?

Arch Cardiovasc Dis 2021 Feb 19;114(2):140-149. Epub 2021 Jan 19.

Department of cardiology, Tours university hospital, 37000 Tours, France.

Ventricular tachycardia has a significant recurrence rate after ablation for several reasons, including inaccessible substrate. A non-invasive technique to ablate any defined areas of myocardium involved in arrhythmogenesis would be a potentially important therapeutic improvement if shown to be safe and effective. Early feasibility studies of single-fraction stereotactic body radiotherapy have demonstrated encouraging results, but rigorous evaluation and follow-up are required. In this document, the basic concepts of stereotactic body radiotherapy are summarized, before focusing on stereotactic arrhythmia radioablation. We describe the effect of radioablation on cardiac tissue and its interaction with intracardiac devices, depending on the dose. The different clinical studies on ventricular tachycardia radioablation are analysed, with a focus on target identification, which is the key feature of this approach. Our document ends with the indications and requirements for practicing this type of procedure in 2020. Finally, because of the limited number of patients treated so far, we encourage multicentre registries with long-term follow-up.
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http://dx.doi.org/10.1016/j.acvd.2020.11.003DOI Listing
February 2021

Specific electrogram characteristics impact substrate ablation target area in patients with scar-related ventricular tachycardia-insights from automated ultrahigh-density mapping.

J Cardiovasc Electrophysiol 2021 Feb 19;32(2):376-388. Epub 2021 Jan 19.

DZHK (German Center for Cardiovascular Research), Berlin, Germany.

Introduction: Substrate-based catheter ablation approaches to ventricular tachycardia (VT) focus on low-voltage areas and abnormal electrograms. However, specific electrogram characteristics in sinus rhythm are not clearly defined and can be subject to variable interpretation. We analyzed the potential ablation target size using automatic abnormal electrogram detection and studied findings during substrate mapping in the VT isthmus area.

Methods And Results: Electrogram characteristics in 61 patients undergoing scar-related VT ablation using ultrahigh-density 3D-mapping with a 64-electrode mini-basket catheter were analyzed retrospectively. Forty-four complete substrate maps with a mean number of 10319 ± 889 points were acquired. Fractionated potentials detected by automated annotation and manual review were present in 43 ± 21% of the entire low-voltage area (<1.0 mV), highly fractionated potentials in 7 ± 8%, late potentials in 13 ± 15%, fractionated late potentials in 7 ± 9% and isolated late potentials in 2 ± 4%, respectively. Highly fractionated potentials (>10 ± 1 fractionations) were found in all isthmus areas of identified VT during substrate mapping, while isolated late potentials were distant from the critical isthmus area in 29%.

Conclusion: The ablation target area varies enormously in size, depending on the definition of abnormal electrograms. Clear linking of abnormal electrograms with critical VT isthmus areas during substrate mapping remains difficult due to a lack of specificity rather than sensitivity. However, highly fractionated, low-voltage electrograms were found to be present in all critical VT isthmus sites.
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http://dx.doi.org/10.1111/jce.14859DOI Listing
February 2021

Incidence, epidemiology, diagnosis and prognosis of atrio-oesophageal fistula following percutaneous catheter ablation: a French nationwide survey.

Europace 2021 Apr;23(4):557-564

Department of Cardiology, University Hospital Rangueil, 31059 Toulouse, France.

Aims: Rate, incidence, risk factors, and optimal management of atrio-oesophageal fistula (AOF) after catheter ablation for atrial fibrillation (AF) remain obscure.

Methods And Results: All French centres performing AF ablation were identified and surveys were sent concerning the number of procedures, eventual cases of AOF, and characteristics of such cases. Eighty-two of the 103 centres (80%) performing AF ablation in France were included, with a total of 129 286 AF ablations since 2006 (93% of the whole procedures in France). Thirty-three AOF were reported (reported rate 0.026% per procedure) with a stable reported annual incidence despite the increasing number of procedures. Sensitivity of computed tomography (CT) scan for AOF was 81%. Mortality was 60%, significantly lower in case of surgical corrective therapy (31 vs. 93%, P = 0.001).

Conclusion: The reported rate of AOF after AF ablation in this nationwide survey was 0.026%, with a stable reported annual incidence over time. A normal CT scan does not rule out the diagnosis and should be repeated in case of suspicion. Prognosis remains poor with a mortality of 60% and crucially dependant of immediate surgical correction. No clear protective strategy has been proven effective.
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http://dx.doi.org/10.1093/europace/euaa278DOI Listing
April 2021

Long-Term Follow-Up of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator: The DAI-T4F Nationwide Registry.

Circulation 2020 Oct 1;142(17):1612-1622. Epub 2020 Oct 1.

Annecy Hospital, France (D.I.).

Background: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce.

Methods: A Nationwide French Registry including all patients with tetralogy of Fallot with an ICD was initiated in 2010 by the French Institute of Health and Medical Research. The primary time to event end point was the time from ICD implantation to first appropriate ICD therapy. Secondary outcomes included ICD-related complications, heart transplantation, and death. Clinical events were centrally adjudicated by a blinded committee.

Results: A total of 165 patients (mean age, 42.2±13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (interquartile range) follow-up of 6.8 (2.5-11.4) years, 78 (47.3%) patients received at least 1 appropriate ICD therapy. The annual incidence of the primary outcome was 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively; =0.03). Overall, 71 (43.0%) patients presented with at least 1 ICD complication, including inappropriate shocks in 42 (25.5%) patients and lead dysfunction in 36 (21.8%) patients. Among 61 (37.0%) patients in primary prevention, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with, respectively, 0, 1, 2, or ≥3 guidelines-recommended risk factors. QRS fragmentation was the only independent predictor of appropriate ICD therapies (hazard ratio, 3.47 [95% CI, 1.19-10.11]), and its integration in a model with current criteria increased the 5-year time-dependent area under the curve from 0.68 to 0.81 (=0.006). Patients with congestive heart failure or reduced left ventricular ejection fraction had a higher risk of nonarrhythmic death or heart transplantation (hazard ratio, 11.01 [95% CI, 2.96-40.95]).

Conclusions: Patients with tetralogy of Fallot and an ICD experience high rates of appropriate therapies, including those implanted in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria including QRS fragmentation might improve risk stratification. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03837574.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.046745DOI Listing
October 2020

Long-Lasting Ventricular Fibrillation in Humans ECG Characteristics and Effect of Radiofrequency Ablation.

Circ Arrhythm Electrophysiol 2020 10 10;13(10):e008639. Epub 2020 Sep 10.

LIRYC Institute/INSERM 1045, Bordeaux University, France (J.D., M. Hocini, F.S., P.J., O.B., M. Haïssaguerre, R.D.).

Background: Studies of ventricular fibrillation (VF) in humans are limited because of the short available duration. We sought to study surface ECG waveforms and effect of ablation in long-lasting VF in patients with left assist devices.

Methods: Continuous 12-lead ECG of 5 episodes of long-lasting VF occurring in 3 patients with left ventricular assist device were analyzed. Spectral analysis (dominant frequency) and quantification of waveform amplitude, regularity (Unbiased Regularity Index), and complexity (Nondipolar Index) were performed over a median of 24 minutes of VF. Radiofrequency ablation was performed during VF in 2 patients.

Results: There was a significant increase in dominant frequency between VF onset and termination but none of the other parameters significantly changed. Some VF parameters varied from patient to patient and from lead to lead. Dominant frequency decreased after radiofrequency ablation in both cases and VF terminated spontaneously shortly after ablation in one case. The previously incessant VFs in these 2 patients did not recur afterward.

Conclusions: VF rate increases over time in patients with left ventricular assist devices and is lowered by ablation. Long-lasting VF may be modified or even terminated by ablation.
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http://dx.doi.org/10.1161/CIRCEP.120.008639DOI Listing
October 2020

Coagulation and heparin requirements during ablation in patients under oral anticoagulant drugs.

J Arrhythm 2020 Aug 19;36(4):644-651. Epub 2020 May 19.

Hematology laboratory University Hospital Rangueil Toulouse France.

Background: Anticoagulation during catheter ablation should be closely monitored with activated clotting time (ACT). However vitamin K antagonists (VKA) or direct oral anticoagulant drugs (DOAC) may act differently on ACT and on heparin needs. The aim of this study was to compare ACT and heparin requirements during catheter ablation under various oral anticoagulant drugs and in controls.

Methods: Sixty consecutive patients referred for ablation were retrospectively included: group I (n = 15, VKA), group 2 (n = 15, uninterrupted rivaroxaban), group 3 (n = 15, uninterrupted apixaban), and group 4 (n = 15, controls). Heparin requirements and ACT were compared throughout the procedure.

Results: Heparin requirements during the procedure were significantly lower in patients under VKA compared to DOAC, but similar between DOAC patients and controls.Activated clotting time values were significantly higher in patients under VKA compared to DOAC and similar in DOAC patients versus controls. Furthermore, anticoagulation control as evaluated by the number/proportion of ACT> 300 as well as the time passed over 300 seconds was significantly better in patients under VKA versus DOAC, without significant differences between DOAC and controls. Finally, the number of patients/ACT with excessive ACT values was significantly higher in VKA versus DOAC patients versus controls.There was no significant difference between rivaroxaban and apixaban for ACT or heparin dosing throughout the procedure.

Conclusion: Vitamin K antagonists allowed less heparin requirement despite reaching higher ACT values and more efficient anticoagulation control (with more excessive values) compared to patients under DOAC therapy and to controls. There was no difference in heparin requirements or ACT between DOAC patients and controls.
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http://dx.doi.org/10.1002/joa3.12357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7411209PMC
August 2020

Implantable cardiac defibrillator leads dysfunction after LVAD implantation.

Pacing Clin Electrophysiol 2020 11 24;43(11):1309-1317. Epub 2020 Jul 24.

Department of Cardiology and Cardiac Surgery, AP-HP CHU Henri Mondor, Créteil, France.

Background: Implantable cardioverter-defibrillator (ICD) lead dysfunction has been reported after left ventricular assist device (LVAD) implantation in limited single-center studies. We aimed at describing and characterizing the incidence of ICD lead parameters dysfunction after LVAD implantation.

Methods: Among the 652 patients enrolled in the ASSIST-ICD study, only patients with an ICD prior to LVAD were included (n = 401). ICD lead parameters dysfunction following LVAD implantation is defined as follows: (a) >50% decrease in sensing threshold, (b) pacing lead impedance increase/decrease by >100Ω, and (c) >50% increase in pacing threshold.

Results: One hundred twenty-two patients with an ICD prior to LVAD had available ICD interrogation reports prior and after LVAD. A total of 67 (55%) patients exhibited at least one significant lead dysfunction: 17 (15%) exhibited >50% decrease in right ventricular (RV) sensing, 51 (42%) had >100 Ω increase/decrease in RV pacing impedance, and 24 (20%) experienced >50% increase in RV pacing threshold. A total of 52 patients experienced ventricular arrhythmia during follow-up and all were successfully detected and treated by the device. All lead dysfunction could be managed conservatively.

Conclusion: More than 50% of LVAD-recipients may experience >1 significant change in lead parameters but none had severe clinical consequences.
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http://dx.doi.org/10.1111/pace.14004DOI Listing
November 2020

Basket catheter-guided ultra-high-density mapping of cardiac arrhythmias: a systematic review and meta-analysis.

Future Cardiol 2020 Nov 1;16(6):735-751. Epub 2020 Jul 1.

Department of Cardiology, cNEP, Cardiac Neuro- & Electrophysiology Research Group, University Heart & Vascular Center Hamburg, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.

Ultra-high-density mapping (HDM) is increasingly used for guidance of catheter ablation in cardiac arrhythmias. While initial results are promising, a systematic evaluation of long-term outcome has not been performed so far. A systematic review and meta-analysis was conducted on studies investigating long-term outcome after Rhythmia HDM-guided atrial fibrillation (AF) or atrial tachycardia catheter ablation. Beyond multiple studies providing novel insights into arrhythmia mechanisms, follow-up data from 17 studies analyzing Rhythmia HDM-guided ablation (1768 patients, 49% with previous ablation) were investigated. Cumulative acute success was 100/90.2%, while 12 months long-term pooled success displayed at 71.6/71.2% (AF/atrial tachycardia). Prospective data are limited, showing similar outcome between HDM-guided and conventional AF ablation. Acute results of HDM-guided catheter ablation are promising, while long-term success is challenged by complex arrhythmogenic substrates. Prospective randomized trials investigating different HDM-guided ablation strategies are warranted and underway.
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http://dx.doi.org/10.2217/fca-2020-0032DOI Listing
November 2020

Creation of sinus rhythm and paced maps using a single acquisition step: the "one acquisition-two maps" technique-a feasibility study.

J Interv Card Electrophysiol 2020 Jun 19. Epub 2020 Jun 19.

Department of Cardiology, University Hospital Rangueil, 31059, Toulouse, Cedex 09, France.

Purpose: Scars and abnormal electrograms may significantly differ according to the activation wavefront. We propose a new fast technique for reliable comparison between sinus rhythm and ventricular pacing using a single map acquisition and the Rhythmia™ 3D mapping system.

Methods: A special programming of the external stimulator was assuring full stable regular paced-beat bigeminy during spontaneous rhythm. A first map was acquired for the spontaneous cardiac beat. Then the window of detection was moved to the following paced beat, and a second map was available after recalculation by the system, depicting activation and voltage of the paced cardiac beat at the same locations, with an exactly the same number of beats in both maps.

Results: Thirty patients with structural heart disease referred for ablation of ventricular tachycardia underwent this protocol, who were compared with 19 similar patients undergoing repeated maps. Duration of the mapping was significantly shorter compared to controls (34 ± 12 vs 57 ± 14 min, p < 0.0001) without differences in the number of electrograms (6978 ± 7067 vs 9554 ± 4424 for sinus rhythm map and 6610 ± 7240 vs 7783 ± 3804 for paced map, p = ns for both). The technique cannot be completed in five patients (17%), because of arrhythmogenicity, mechanical right bundle branch block, hemodynamical impairment, or bradycardia.

Conclusion: We propose a novel technique for performing maps during sinus rhythm and ventricular pacing using a single acquisition. Beside time saving, this will allow more strict comparisons between different activation wavefronts.
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http://dx.doi.org/10.1007/s10840-020-00793-zDOI Listing
June 2020

Joint Position Paper of the Working Group of Pacing and Electrophysiology of the French Society of Cardiology and the French Society of Diagnostic and Interventional Cardiac and Vascular Imaging on magnetic resonance imaging in patients with cardiac electronic implantable devices.

Arch Cardiovasc Dis 2020 Jun - Jul;113(6-7):473-484. Epub 2020 May 27.

Clinique Pasteur, 31076 Toulouse, France.

Magnetic resonance imaging (MRI) has become the reference imaging technique for the management of a large number of diseases. The number of MRI examinations increases every year, simultaneously with the number of patients receiving a cardiac electronic implantable device (CEID). The presence of a CEID was considered an absolute contraindication for MRI for many years. The progressive replacement of conventional pacemakers and defibrillators by "magnetic resonance (MR)-conditional" CEIDs and recent data on the safety of MRI in patients with "MR-non-conditional" CEIDs have gradually increased the demand for MRI in patients with a CEID. However, some risks are associated with MRI in CEID carriers, even with MR-conditional devices, because these devices are not "MR safe". Specific programming of the device in "MR mode" and monitoring patients during MRI remain mandatory for all patients with a CEID. A standardized patient workflow based on an institutional protocol should be established in each institution performing such examinations. This joint position paper of the Working Group of Pacing and Electrophysiology of the French Society of Cardiology and the French Society of Diagnostic and Interventional Cardiac and Vascular Imaging describes the effect of and risks associated with MRI in CEID carriers. We propose recommendations for patient workflow and monitoring and CEID programming in MR-conditional, "MR-conditional non-guaranteed" and MR-non-conditional devices.
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http://dx.doi.org/10.1016/j.acvd.2020.03.015DOI Listing
September 2020

Position paper concerning the competence, performance and environment required for the practice of ablation in children and in congenital heart disease.

Arch Cardiovasc Dis 2020 Aug - Sep;113(8-9):492-502. Epub 2020 May 24.

Department of Cardiology, LIRYC Institute/Bordeaux University Hospital, 33600 Pessac, France.

The population of patients with congenital heart disease (CHD) is continuously increasing, and a significant proportion of these patients will experience arrhythmias because of the underlying congenital heart defect itself or as a consequence of interventional or surgical treatment. Arrhythmias are a leading cause of mortality, morbidity and impaired quality of life in adults with CHD. Arrhythmias may also occur in children with or without CHD. In light of the unique issues, challenges and considerations involved in managing arrhythmias in this growing, ageing and heterogeneous patient population and in children, it appears both timely and essential to critically appraise and synthesize optimal treatment strategies. The introduction of catheter ablation techniques has greatly improved the treatment of cardiac arrhythmias. However, catheter ablation in adults or children with CHD and in children without CHD is more technically demanding, potentially causing various complications, and thus requires a high level of expertise to maximize success rates and minimize complication rates. As French recommendations regarding required technical competence and equipment are lacking in this situation, the Working Group of Pacing and Electrophysiology of the French Society of Cardiology and the Affiliate Group of Paediatric and Adult Congenital Cardiology have decided to produce a common position paper compiled from expert opinions from cardiac electrophysiology and paediatric cardiology. The paper details the features of an interventional cardiac electrophysiology centre that are required for ablation procedures in adults with CHD and in children, the importance of being able to diagnose, monitor and manage complications associated with ablations in these patients and the supplemental hospital-based resources required, such as anaesthesia, surgical back-up, intensive care, haemodynamic assistance and imaging. Lastly, the need for quality evaluations and French registries of ablations in these populations is discussed. The purpose of this consensus statement is therefore to define optimal conditions for the delivery of invasive care regarding ablation of arrhythmias in adults with CHD and in children, and to provide expert and - when possible - evidence-based recommendations on best practice for catheter-based ablation procedures in these specific populations.
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http://dx.doi.org/10.1016/j.acvd.2020.02.002DOI Listing
September 2020

Termination of sustained ventricular fibrillation by catheter ablation.

Eur Heart J 2020 08;41(30):2847

Cardiology, University Hospital Rangueil, 1 av Jean Poulhès, 31059 Toulouse, France.

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http://dx.doi.org/10.1093/eurheartj/ehaa243DOI Listing
August 2020

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary.

J Arrhythm 2020 Feb 3;36(1):1-58. Epub 2020 Jan 3.

University of Pennsylvania Philadelphia PA USA.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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http://dx.doi.org/10.1002/joa3.12264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011820PMC
February 2020

Chest pain in Brugada syndrome: Prevalence, correlations, and prognosis role.

Pacing Clin Electrophysiol 2020 04 26;43(4):365-373. Epub 2020 Feb 26.

Department of Cardiology, University Hospital Rangueil, Toulouse, France.

Background: Brugada syndrome (BrS) is sometimes diagnosed because of chest pain. Prevalence and characteristics of such BrS patients are unknown.

Methods: A total of 200 BrS probands were retrospectively included. BrS diagnosis made because of chest pain (n = 34, 17%) was compared to the other ones.

Results: BrS probands with diagnosis because of chest pain had significantly more often smoker habits, increased body mass index, and familial history of coronary artery disease but less frequently previous resuscitated sudden death/syncope or atrial fibrillation. Presence of coronary spasm and familial coronary artery disease were independently associated with BrS diagnosed because of chest pain. They presented more often with spontaneous type 1 ST elevation (59% vs 26%, P = .0004) and higher ST elevation during the episode of chest pain compared to other patients or compared to baseline electrocardiogram after chest pain resumption. ST elevation during chest pain was lower compared to ajmaline test. A total of 20% of them had significant coronary artery disease and four (11%) had coronary spasm, and they experienced more often recurrent chest pain episodes (24% vs 5%, P = .0002). Presence of chest pain at BrS diagnosis was not correlated to future arrhythmic events in univariate analysis. Only previous sudden cardiac death (SD)/syncope and familial SD were still significantly associated with outcome in multivariate analysis.

Conclusion: Chest pain is a common cause for BrS diagnosis, although major part is not apparently explained by ischemic heart disease. Mechanisms leading to chest main remain unknown in the other ones. ST elevation is higher in this situation but does not seem to carry poor prognosis.
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http://dx.doi.org/10.1111/pace.13881DOI Listing
April 2020

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: executive summary.

Europace 2020 03;22(3):450-495

University of Pennsylvania, Philadelphia, Pennsylvania.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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http://dx.doi.org/10.1093/europace/euz332DOI Listing
March 2020

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias.

J Interv Card Electrophysiol 2020 Oct;59(1):145-298

University of Pennsylvania, Philadelphia, PA, USA.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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http://dx.doi.org/10.1007/s10840-019-00663-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223859PMC
October 2020

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary.

J Interv Card Electrophysiol 2020 Oct;59(1):81-133

University of Pennsylvania, Philadelphia, PA, USA.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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http://dx.doi.org/10.1007/s10840-019-00664-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508755PMC
October 2020

Ultra-High-Density Activation Mapping to Aid Isthmus Identification of Atrial Tachycardias in Congenital Heart Disease.

JACC Clin Electrophysiol 2019 12 30;5(12):1459-1472. Epub 2019 Oct 30.

LIRYC/Hopital du Haut Leveque, Bordeaux, France.

Objectives: A new electroanatomic mapping system (Rhythmia, Boston Scientific, Marlborough, Massachusetts) using a 64-electrode mapping basket is now available; we systematically assessed its use in complex congenital heart disease (CHD).

Background: The incidence of atrial arrhythmias post-surgery for CHD is high. Catheter ablation has emerged as an effective treatment, but is hampered by limitations in the mapping system's ability to accurately define the tachycardia circuit.

Methods: Mapping and ablation data of 61 patients with CHD (35 males, age 45 ± 14 years) from 8 tertiary centers were reviewed.

Results: Causes were as follows: Transposition of Great Arteries (atrial switch) (n = 7); univentricular physiology (Fontans) (n = 8); Tetralogy of Fallot (n = 10); atrial septal defect (ASD) repair (n = 15); tricuspid valve (TV) anomalies (n = 10); and other (n = 11). The total number of atrial arrhythmias was 86. Circuits were predominantly around the tricuspid valve (n = 37), atriotomy scar (n = 10), or ASD patch (n = 4). Although the majority of peri-tricuspid circuits were cavo-tricuspid-isthmus dependent (n = 30), they could follow a complex route between the annulus and septal resection, ASD patch, coronary sinus, or atriotomy. Immediate ablation success was achieved in all but 2 cases; with follow-up of 12 ± 8 months, 7 patients had recurrence.

Conclusions: We demonstrate the feasibility of the basket catheter for mapping complex CHD arrhythmias, including with transbaffle and transhepatic access. Although the circuits often involve predictable anatomic landmarks, the precise critical isthmus is often difficult to predict empirically. Ultra-high-density mapping enables elucidation of circuits in this complex anatomy and allows successful treatment at the isthmus with a minimal lesion set.
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http://dx.doi.org/10.1016/j.jacep.2019.08.001DOI Listing
December 2019

Severe and uniform bi-atrial remodeling measured by dominant frequency analysis in persistent atrial fibrillation unresponsive to ablation.

J Interv Card Electrophysiol 2020 Nov 13;59(2):431-440. Epub 2019 Dec 13.

Service of Cardiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.

Background: High values of ECG and intracardiac dominant frequency (DF) are indicative of significant atrial remodeling in persistent atrial fibrillation (peAF). We hypothesized that patients with peAF unresponsive to ablation display higher ECG and intracardiac DFs than those remaining in sinus rhythm (SR) on the long term.

Methods: Forty consecutive patients underwent stepwise ablation for peAF (sustained duration 19 ± 11 months). Electrograms were recorded before ablation at 13 left atrium (LA) sites and at the right atrial appendage (RAA) and coronary sinus (CS) synchronously to the ECG. DF was defined as the highest peak within the power spectrum.

Results: peAF was terminated within the LA in 28 patients (left-terminated [LT]), whereas 12 patients remaining in AF after ablation (not left-terminated [NLT]) were cardioverted. Over a mean follow-up of 34 ± 14 months, all 12 NLT patients had a recurrence. Of the LT patients, 71% had a recurrence (20/28, LT_Rec), while 29% remained in SR throughout the follow-up (8/28, LT_SR). DF values and correlations between pairs of LA appendage (LAA), RAA, and CS DFs showed distinctive patterns among the subgroups. The NLT subgroup displayed the highest ECG and intracardiac DFs, with strong intragroup homogeneity between pairs of CS and LAA DFs, and to a lesser extent between pairs of CS and RAA DFs. Conversely, the LT_SR subgroup showed the lowest DFs, with significant intragroup heterogeneity between pairs of CS and both LAA and RAA DFs.

Conclusions: Patients with peAF unresponsive to ablation show high surface and intracardiac DFs indicative of severe and uniform bi-atrial remodeling.
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http://dx.doi.org/10.1007/s10840-019-00681-1DOI Listing
November 2020

Does Ventricular Tachycardia Ablation Targeting Local Abnormal Ventricular Activity Elimination Reduce Ventricular Fibrillation Incidence?

Circ Arrhythm Electrophysiol 2019 12 25;12(12):e006857. Epub 2019 Nov 25.

LIRYC, Bordeaux University, CHU de Bordeaux, France (T.K., A.L., F.S., R.M., K.V., A.F., M.T., Y.N., N.T., G.M., G.C., C.A.M., F.B., J.D., N.K., T.P., A.D., N.D., H.C., M. Hocini, M. Haissaguerre, P.J.).

Background: Various strategies for ablation of ventricular tachycardia (VT) have been described, but their impact on ventricular fibrillation (VF) is largely unknown. The aim of our study was to assess the effect of substrate-based VT ablation targeting local abnormal ventricular activity (LAVA) on recurrent VF events in patients with structural heart disease.

Methods: A retrospective 2-center study was performed on patients with structural heart disease and both VT and VF, with incident VT ablation procedures targeting LAVAs. Generalized estimating equations with a Poisson loglinear model were used to assess the impact of catheter ablation on VF episodes. The change in VF events before and after catheter ablation was compared with matched controls without ablation.

Results: From a total of 686 patients with an incident VT ablation procedure targeting LAVAs, 21 patients (age, 57±14 years; left ventricular ejection fraction, 30±10%) had both VT and VF and met inclusion criteria. A total of 80 VF events were recorded in the implantable cardioverter-defibrillator logs the 6 months preceding ablation. Complete and partial LAVA elimination was achieved in 11 (52%) and 10 (48%) patients, respectively. Catheter ablation was associated with a highly significant reduction in VF recurrences (<0.0001), which were limited to 3 (14%) patients at 6 months. The total number of VF events thereby decreased from 80 to 3, from a median of 1.0 (range, 1-29) to 0.0 (range, 0-1) in the 6 months before and after ablation, respectively. The reduction in VF events was significantly greater in patients with catheter ablation compared with 21 matched controls during 6-month periods following and preceding a baseline assessment (Poisson β-coefficient, 1.39; =0.0003).

Conclusions: Substrate-guided VT ablation targeting LAVAs may be associated with a significant reduction in recurrent VF, suggesting that VT and VF share overlapping arrhythmogenic substrates in patients with structural heart disease.
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http://dx.doi.org/10.1161/CIRCEP.118.006857DOI Listing
December 2019

Feasibility of fast ventricular tachycardia mapping using the Rhythmia ™ system in a patient with an Impella ™.

Indian Pacing Electrophysiol J 2020 Jan - Feb;20(1):33-34. Epub 2019 Nov 18.

Department of Cardiology, University Hospital Rangueil, Toulouse, France.

Use of 3D navigation systems may be sometimes impossible in patients with left ventricular assist devices because of major electromagnetical interferences with some 3D systems based on magnetic localization. Mapping with the Rhythmia ™ system in patients implanted with an Impella ™ is described to be non feasible. We relate how to overcome this technical issues in this case.
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http://dx.doi.org/10.1016/j.ipej.2019.11.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6994303PMC
November 2019

Management of sustained arrhythmias for patients with cardiogenic shock in intensive cardiac care units.

Arch Cardiovasc Dis 2019 Dec 13;112(12):781-791. Epub 2019 Nov 13.

LIRYC institute, Bordeaux university, Bordeaux university hospital, 33000 Bordeaux, France.

Cardiac arrhythmias that occur in patients referred to intensive care units worsen symptoms and outcomes and need urgent correction, especially in patients admitted for refractory heart failure. Electrical storm is a frequent reason for referral to an intensive care unit. Specific, efficient and rapid management of patients presenting with various arrhythmias is therefore mandatory and procedures should be known by any physician involved in an intensive care unit. This article reviews the current knowledge on the management of supraventricular and ventricular arrhythmias in this setting, from medications and sedation to ablation and more exceptional therapy. It also covers the occasional indications of resynchronization in refractory heart failure and the interest for haemodynamic assistance when specific therapy fails.
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http://dx.doi.org/10.1016/j.acvd.2019.10.002DOI Listing
December 2019

Atrial Tachycardia With Atrial Activation Duration Exceeding the Tachycardia Cycle Length: Mechanisms and Prevalence.

JACC Clin Electrophysiol 2019 08 31;5(8):907-916. Epub 2019 Jul 31.

Department of Cardiology, University Hospital Haut-Lévèque, Pessac, France; LIRYC Institute/INSERM 1045, Bordeaux University Hospital, Bordeaux, France.

Objectives: This study sought to identify atrial tachycardia (AT) demonstrating atrial activation duration (AAD) lasting longer than the length of the tachycardia cycle (TCL); to assess AT prevalence; and to evaluate the mechanisms and characteristics associated with these AT episodes by using the Rhythmia system (Boston Scientific, Marlborough, Massachusetts).

Background: Ultra-high-density mapping allows very accurate characterization of mechanisms involved in AT. Some complex patterns may involve AAD which is longer than the tachycardia cycle length (TCL) which makes maps difficult to interpret. Prevalence and characteristics of such ATs are unknown.

Methods: A cohort of 100 consecutive patients undergoing ablation of 125 right (n = 21) or left (n = 104) ATs using ultra-high-density mapping were retrospectively included. Offline calculation of right or left AAD was compared to TCL.

Results: Mean TCL was 293 ± 65 ms, and mean AAD was 291 ± 74 ms (p = NS). AT mechanisms were macro-re-entry in 74 cases (59%), localized re-entry in 27 cases (22%), and focal AT in 21 cases (17%) (types were mixed in 3 cases). Fifteen ATs (12%) had AADs that were longer than the TCL (71 ± 45 ms longer, from 10 to 150 ms). TCL was equal to the AAD in 97 ATs (78%), whereas 13 ATs (10%) had AAD shorter than the TCL (focal AT in each case). There were no differences between right and left atria for prevalence of ATs with AADs that were longer than the TCLs. There were significant differences in AT mechanisms according to the AAD-to-TCL ratio (p < 0.0001), with localized re-entry showing more often that AAD was longer than the TCL compared to that in focal AT and macro-re-entry.

Conclusions: ATs with AAD lasting longer than the TCL were present in approximately 10% of the ATs referred for ablation, mostly in ATs caused by localized re-entry. Ultra-high-density mapping allows detection of these complex patterns of activation.
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http://dx.doi.org/10.1016/j.jacep.2019.04.015DOI Listing
August 2019

Correlations between arrhythmogenic substrate and noninvasive risk stratification in ischemic heart disease patients modifications by radiofrequency ablation.

J Cardiovasc Electrophysiol 2019 11 29;30(11):2344-2352. Epub 2019 Aug 29.

Department of Cardiology, University Hospital Rangueil, Toulouse, France.

Introduction: Several noninvasive risk factors for ventricular arrhythmias have been described in postmyocardial infarction (MI) patients, whose relationships with scar characteristics and modifications by ablation are unknown.

Methods: Twenty-two patients with previous MI referred for ventricular tachycardia ablation were prospectively included. ECG, heart rate variability (HRV), signal-averaged ECG (SA-ECG), and T wave alternans (TWA) were performed before and after radiofrequency ablation. Scar areas were correlated to preablation parameters. Pre and postablation parameters were furthermore compared.

Results: Left ventricular ejection fraction and some spectral and time-domain HRV parameters were significantly correlated to the scar areas. QRS duration was larger after vs before ablation (120 ± 29 vs 105 ± 22 msec, P = .01). No significant modification in time or spectral domain of HRV was observed. There was no significant change in TWA and SA-ECG before and after ablation. Borderline decreases in quantitative TWA parameters were noted in patients with positive TWA and successful ablation procedure.

Conclusion: Some noninvasive risk factors were linked to the scar areas, but few were significantly modified after ablation. Larger populations are needed to demonstrate significant differences or correlations.
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http://dx.doi.org/10.1111/jce.14136DOI Listing
November 2019