Journal: Europace

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Abstract

Human-based approaches to pharmacology and cardiology: an interdisciplinary and intersectorial workshop.

Rodriguez B, Carusi A, Abi-Gerges N, Ariga R, ... Wallman M, Zhou X
Both biomedical research and clinical practice rely on complex datasets for the physiological and genetic characterization of human hearts in health and disease. Given the complexity and variety of approaches and recordings, there is now growing recognition of the need to embed computational methods in cardiovascular medicine and science for analysis, integration and prediction. This paper describes a Workshop on Computational Cardiovascular Science that created an international, interdisciplinary and inter-sectorial forum to define the next steps for a human-based approach to disease supported by computational methodologies. The main ideas highlighted were (i) a shift towards human-based methodologies, spurred by advances in new in silico, in vivo, in vitro, and ex vivo techniques and the increasing acknowledgement of the limitations of animal models. (ii) Computational approaches complement, expand, bridge, and integrate in vitro, in vivo, and ex vivo experimental and clinical data and methods, and as such they are an integral part of human-based methodologies in pharmacology and medicine. (iii) The effective implementation of multi- and interdisciplinary approaches, teams, and training combining and integrating computational methods with experimental and clinical approaches across academia, industry, and healthcare settings is a priority. (iv) The human-based cross-disciplinary approach requires experts in specific methodologies and domains, who also have the capacity to communicate and collaborate across disciplines and cross-sector environments. (v) This new translational domain for human-based cardiology and pharmacology requires new partnerships supported financially and institutionally across sectors. Institutional, organizational, and social barriers must be identified, understood and overcome in each specific setting.

Europace: 30 Nov 2015; epub ahead of print
Rodriguez B, Carusi A, Abi-Gerges N, Ariga R, ... Wallman M, Zhou X
Europace: 30 Nov 2015; epub ahead of print | PMID: 26622055
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Abstract

Geometrical considerations in cardiac electrophysiology and arrhythmogenesis.

Winter J, Shattock MJ
The rate of repolarization (RRepol) and so the duration of the cardiac action potential are determined by the balance of inward and outward currents across the cardiac membrane (net ionic current). Plotting action potential duration (APD) as a function of the RRepol reveals an inverse non-linear relationship, arising from the geometric association between these two factors. From the RRepol-APD relationship, it can be observed that a longer action potential will exhibit a greater propensity to shorten, or prolong, for a given change in the RRepol (i.e. net ionic current), when compared with one that is initially shorter. This observation has recently been used to explain why so many interventions that prolong the action potential exert a greater effect at slow rates (reverse-rate dependence). In this article, we will discuss the broader implications of this simple principle and examine how common experimental observations on the electrical behaviour of the myocardium may be explained in terms of the RRepol-APD relationship. An argument is made, with supporting published evidence, that the non-linear relationship between the RRepol and APD is a fundamental, and largely overlooked, property of the myocardium. The RRepol-APD relationship appears to explain why interventions and disease with seemingly disparate mechanisms of action have similar electrophysiological consequences. Furthermore, the RRepol-APD relationship predicts that prolongation of the action potential, by slowing repolarization, will promote conditions of dynamic electrical instability, exacerbating several electrophysiological phenomena associated with arrhythmogenesis, namely, the rate dependence of dispersion of repolarization, APD restitution, and electrical alternans.

Europace: 19 Nov 2015; epub ahead of print
Winter J, Shattock MJ
Europace: 19 Nov 2015; epub ahead of print | PMID: 26585597
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Abstract

Imaging for assessment of sudden death risk: current role and future prospects.

Suzuki T, Nazarian S, Jerosch-Herold M, Chugh SS
Sudden cardiac death (SCD) remains a major public health problem and there is an urgent need to maximize the impact of primary prevention using the implantable defibrillator. While implantable defibrillators are of utility for prevention of SCD, current methods of selecting candidates have significant shortcomings. Major advancements have occurred in the field of cardiac imaging, with significant potential to identify novel cardiac substrates for improved prediction. While assessment of the left ventricular ejection fraction remains the current major predictor, it is likely that several novel imaging markers will be incorporated into future risk stratification approaches. The goal of this review is to discuss the current status and future potential of cardiac imaging modalities to enhance risk stratification for SCD.

Europace: 20 Apr 2016; epub ahead of print
Suzuki T, Nazarian S, Jerosch-Herold M, Chugh SS
Europace: 20 Apr 2016; epub ahead of print | PMID: 27098112
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Abstract

Ventricular arrhythmia during ajmaline challenge for the Brugada syndrome.

Dobbels B, De Cleen D, Ector J
The Brugada syndrome is a genetic disease characterized by an abnormal electrocardiogram (ECG) and an elevated risk of sudden cardiac death. Sodium channel blockers (SCBs), such as ajmaline, are used to unmask the characteristic type 1 Brugada electrocardiographic pattern. We review the literature on the incidence of ventricular arrhythmia (VA) during SCB challenge. We evaluate the clinical and electrocardiographic characteristics of these patients as well as their prognosis. All articles published from January 2000 until August 2015, in which the incidence and predictors of VAs during SCB challenge were reported, are reviewed. The occurrence of VA during SCB challenge ranges from 0 to 17.8%. The weighted average for induction of any VA during sodium blocking challenge is 2.4%; for non-sustained ventricular tachycardia (VT), it is 0.34% and for sustained VT 0.59%. No fatal cases were reported. Predictors may be young age, conduction disturbance at baseline ECG, and mutations in the SCN5A gene. All other clinical and electrocardiographic characteristics failed to be consistent predictors. Life-threatening arrhythmias during SCB challenge are not an exceptional event. Therefore, provocation testing must necessarily be performed in an appropriate environment in which advanced life support facilities are present. Patients who have a higher risk for induced arrhythmias might be those who display a conduction disturbance at baseline ECG or have certain SCN5A mutations or are of a younger age. However, survivors of these induced arrhythmias do not seem to suffer from a worse prognosis.

Europace: 03 Mar 2016; epub ahead of print
Dobbels B, De Cleen D, Ector J
Europace: 03 Mar 2016; epub ahead of print | PMID: 26941343
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Abstract

Atrial high-rate episodes and stroke prevention.

Camm AJ, Simantirakis E, Goette A, Lip GY, ... Diener HC, Kirchhof P
While the benefit of oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation (AF) is well established, it is not known whether oral anticoagulation is indicated in patients with atrial high-rate episodes (AHRE) recorded on a cardiac implantable electronic device, sometimes also called subclinical AF, and lasting for at least 6 min in the absence of clinically diagnosed AF. Clinical evidence has shown that short episodes of rapid atrial tachycarrhythmias are often detected in patients presenting with stroke and transient ischaemic attack. Patients with AHRE have a higher likelihood of suffering from subsequent strokes, but their stroke rate seems lower than in patients with diagnosed AF, and not all AHRE episodes correspond to AF. The prognostic and pathological significance of AHRE is not yet fully understood. Clinical trials of OAC therapy are being conducted to determine whether therapeutic intervention would be beneficial to patients experiencing AHRE in terms of reducing the risk of stroke.

Europace: 04 Oct 2016; epub ahead of print
Camm AJ, Simantirakis E, Goette A, Lip GY, ... Diener HC, Kirchhof P
Europace: 04 Oct 2016; epub ahead of print | PMID: 27702868
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Abstract

Traditional and novel electrocardiographic conduction and repolarization markers of sudden cardiac death.

Tse G, Yan BP
Sudden cardiac death, frequently due to ventricular arrhythmias, is a significant problem globally. Most affected individuals do not arrive at hospital in time for medical treatment. Therefore, there is an urgent need to identify the most-at-risk patients for insertion of prophylactic implantable cardioverter defibrillators. Clinical risk markers derived from electrocardiography are important for this purpose. They can be based on repolarization, including corrected QT (QTc) interval, QT dispersion (QTD), interval from the peak to the end of the T-wave (Tpeak - Tend), (Tpeak - Tend)/QT, T-wave alternans (TWA), and microvolt TWA. Abnormal repolarization properties can increase the risk of triggered activity and re-entrant arrhythmias. Other risk markers are based solely on conduction, such as QRS duration (QRSd), which is a surrogate marker of conduction velocity (CV) and QRS dispersion (QRSD) reflecting CV dispersion. Conduction abnormalities in the form of reduced CV, unidirectional block, together with a functional or a structural obstacle, are conditions required for circus-type or spiral wave re-entry. Conduction and repolarization can be represented by a single parameter, excitation wavelength (λ = CV × effective refractory period). λ is an important determinant of arrhythmogenesis in different settings. Novel conduction-repolarization markers incorporating λ include Lu et al.\' index of cardiac electrophysiological balance (iCEB: QT/QRSd), [QRSD× (Tpeak - Tend)/QRSd] and [QRSD × (Tpeak - Tend)/(QRSd × QT)] recently proposed by Tse and Yan. The aim of this review is to provide up to date information on traditional and novel markers and discuss their utility and downfalls for risk stratification.

Europace: 04 Oct 2016; epub ahead of print
Tse G, Yan BP
Europace: 04 Oct 2016; epub ahead of print | PMID: 27702850
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Abstract

Current and future developments in the field of central sleep apnoea.

Bekfani T, Abraham WT
Central sleep apnoea (CSA) occurs in ∼30-50% of patients with heart failure (HF) with reduced left ventricular ejection fraction (LVEF) and in as much as in 18-30% of patients with preserved LVEF. In HF patients, it is characterized by periodic breathing also known as the Cheyne-Stokes respiration followed by pauses of breathing. Central sleep apnoea remains often unrecognized due to its chronic and insidious incidences. Patients may report excessive daytime somnolence, poor sleep quality, nocturnal angina, recurrent arrhythmias, refractory HF symptoms, or demonstrate abnormal respiratory pattern or apnoeas. The pathogenesis of CSA remains incompletely understood, but changes in CO2 above and below the apnoea threshold play a major role in its pathogenesis. The presence of CSA in patients with HF is associated with some neurohumoral and haemodynamic responses that are detrimental to the failing heart including increased morbidity and mortality. The development of successful therapies targeting CSA and its harmful downstream effects is therefore important. Several different therapies from medications to implantable devices have been tested with varying effects and primarily in small non-randomized and/or single-centre studies. Large studies to date have been disappointing, but therapeutic options targeting the physiology of the disease may herald a new era in understanding and treating CSA.

Europace: 27 May 2016; epub ahead of print
Bekfani T, Abraham WT
Europace: 27 May 2016; epub ahead of print | PMID: 27234869
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Abstract

Infection control in implantation of cardiac implantable electronic devices: current evidence, controversial points, and unresolved issues.

Korantzopoulos P, Sideris S, Dilaveris P, Gatzoulis K, Goudevenos JA
A significant increase in the implantation of cardiac implantable electronic devices (CIEDs) is evident over the past years, while there is evidence for a disproportionate increase in CIED-related infections. The cumulative probability of device infection seems to be higher in implantable cardioverter defibrillator and in cardiac resynchronization therapy patients compared with permanent pacemaker patients. Given that more than a half of CIED infections are possibly related to the operative procedure, there is a need for effective periprocedural infection control. However, many of the current recommendations are empirical and not evidence-based, while questions, unresolved issues, and conflicting evidence arise. The perioperative systemic use of antibiotics confers significant benefit in prevention of CIED infections. However, there are no conclusive data regarding the specific value of each agent in different clinical settings, the value of post-operative antibiotic treatment as well as the optimal duration of therapy. The merit of local pocket irrigation with antibiotic and/or antiseptic agents remains unproved. Of note, recent evidence indicates that the application of antibacterial envelopes into the device pocket markedly decreases the infection risk. In addition, limited reports on strict integrated infection control protocols show a dramatic reduction in infection rates in this setting and therefore deserve further attention. Finally, the relative impact of particular factors on the infection risk, including the type of the CIED, patients\' individual characteristics and comorbidities, should be further examined since it may facilitate the development of tailored prophylactic interventions for each patient.

Europace: 29 Oct 2015; epub ahead of print
Korantzopoulos P, Sideris S, Dilaveris P, Gatzoulis K, Goudevenos JA
Europace: 29 Oct 2015; epub ahead of print | PMID: 26516219
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Abstract

QT interval variability in body surface ECG: measurement, physiological basis, and clinical value: position statement and consensus guidance endorsed by the European Heart Rhythm Association jointly with the ESC Working Group on Cardiac Cellular Electrophysiology.

Baumert M, Porta A, Vos MA, Malik M, ... Tereshchenko LG, Volders PG
This consensus guideline discusses the electrocardiographic phenomenon of beat-to-beat QT interval variability (QTV) on surface electrocardiograms. The text covers measurement principles, physiological basis, and clinical value of QTV. Technical considerations include QT interval measurement and the relation between QTV and heart rate variability. Research frontiers of QTV include understanding of QTV physiology, systematic evaluation of the link between QTV and direct measures of neural activity, modelling of the QTV dependence on the variability of other physiological variables, distinction between QTV and general T wave shape variability, and assessing of the QTV utility for guiding therapy. Increased QTV appears to be a risk marker of arrhythmic and cardiovascular death. It remains to be established whether it can guide therapy alone or in combination with other risk factors. QT interval variability has a possible role in non-invasive assessment of tonic sympathetic activity.

Europace: 28 Jan 2016; epub ahead of print
Baumert M, Porta A, Vos MA, Malik M, ... Tereshchenko LG, Volders PG
Europace: 28 Jan 2016; epub ahead of print | PMID: 26823389
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Abstract

Long-term outcome of \'super-responder\' patients to cardiac resynchronization therapy.

Zecchin M, Proclemer A, Magnani S, Vitali-Serdoz L, ... Sinagra G, Proclemer A
To evaluate the long-term changes of clinical and echocardiographic parameters, the incidence of cardiac events and parameters associated with late cardiac events in \'super-responders\' to cardiac resynchronization therapy (CRT) with [CRT defibrillator (CRT-D)] or without defibrillator back-up.Methods and results: In all consecutive patients treated with CRT in two Italian centres (Trieste and Udine) with left ventricular ejection fraction (LVEF) ≤0.35 at implantation (Timp) and LVEF > 0.50 1 and/or 2 years (Tnorm) after implantation, the long-term outcome and the evolution of echocardiographic parameters were assessed; factors associated with a higher risk of cardiac events, defined as hospitalization or death for heart failure (HF), sudden death, or CRT-D appropriate interventions, were also analysed. Among the 259 patients evaluated, 62 (24%) had LVEF ≥ 0.50 at Tnorm (n = 44 with at 1 year, n = 18 at 2 years). During a mean follow-up of 68 ± 30 months, one cardiac death (for HF) and eight cardiovascular events (two hospitalization for HF and six appropriate CRT-D interventions) occurred. At the last echo evaluation (Tfup) performed 51 ± 26 months after Timp, LVEF was <0.50 in five patients (>0.45 in four of them). At univariable analysis, only LV end-systolic volume evaluated at Tfup was associated with a higher risk of cardiac events during follow-up.Conclusion: In \'super-responders\' to CRT long-term outcome is excellent. However, cardiac events, mainly CRT-D appropriate interventions, can occur despite the persistence of LVEF > 0.50. Early identification of these patients is still an unsolved issue.

Europace: 04 Nov 2013; epub ahead of print
Zecchin M, Proclemer A, Magnani S, Vitali-Serdoz L, ... Sinagra G, Proclemer A
Europace: 04 Nov 2013; epub ahead of print | PMID: 24189477
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Abstract

The use of wearable cardioverter-defibrillators in Europe: results of the European Heart Rhythm Association survey.

Lenarczyk R, Potpara TS, Haugaa KH, Hernández-Madrid A, ... European Heart Rhythm Association, Conducted by the Scientific Initiatives Committee European Heart Rhythm Association
The aim of this European Heart Rhythm Association (EHRA) survey was to collect data on the use of wearable cardioverter-defibrillators (WCDs) among members of the EHRA electrophysiology research network. Of the 50 responding centres, 23 (47%) reported WCD use. Devices were fully reimbursed in 17 (43.6%) of 39 respondents, and partially reimbursed in 3 centres (7.7%). Eleven out of 20 centres (55%) reported acceptable patients\' compliance (WCD worn for >90% of time). The most common indications for WCD (8 out of 10 centres; 80%) were covering the period until re-implantation of ICD explanted due to infection, in patients with left ventricular impairment due to myocarditis or recent myocardial infarction and those awaiting heart transplantation. Patient life expectancy of <12 months and poor compliance were the most commonly reported contraindications for WCD (24 of 46 centres, 52.2%). The major problems encountered by physicians managing patients with WCD were costs (8 of 18 centres, 44.4%), non-compliance, and incorrect use of WCD. Four of 17 centres (23.5%) reported inappropriate WCD activations in <5% of patients. The first shock success rate in terminating ventricular arrhythmias was 95-100% in 6 of 15 centres (40%), 85-95% in 4 (26.7%), 75-85% in 2 (13.3%), and <75% in 3 centres (20%). The survey has shown that the use of WCD in Europe is still restricted and depends on reimbursement. Patients\' compliance remains low. Heterogeneity of indications for WCD among centres underscores the need for further research and a better definition of indications for WCD in specific patient groups.

Europace: 03 Feb 2016; 18:146-50
Lenarczyk R, Potpara TS, Haugaa KH, Hernández-Madrid A, ... European Heart Rhythm Association, Conducted by the Scientific Initiatives Committee European Heart Rhythm Association
Europace: 03 Feb 2016; 18:146-50 | PMID: 26842735
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Abstract

The 12-lead electrocardiogram and risk of sudden death: current utility and future prospects.

Narayanan K, Chugh SS
More than 100 years after it was first invented, the 12-lead electrocardiogram (ECG) continues to occupy an important place in the diagnostic armamentarium of the practicing clinician. With the recognition of relatively rare but important clinical entities such as Wolff-Parkinson-White and the long QT syndrome, this clinical tool was firmly established as a test for assessing risk of sudden cardiac death (SCD). However, over the past two decades the role of the ECG in risk prediction for common forms of SCD, for example in patients with coronary artery disease, has been the focus of considerable investigation. Especially in light of the limitations of current risk stratification approaches, there is a renewed focus on this broadly available and relatively inexpensive test. Various abnormalities of depolarization and repolarization on the ECG have been linked to SCD risk; however, more focused work is needed before they can be deployed in the clinical arena. The present review summarizes the current knowledge on various ECG risk markers for prediction of SCD and discusses some future directions in this field.

Europace: 03 Feb 2016; 17:ii7-ii13
Narayanan K, Chugh SS
Europace: 03 Feb 2016; 17:ii7-ii13 | PMID: 26842119
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Abstract

Replacement of implantable cardioverter defibrillators and cardiac resynchronization therapy devices: results of the European Heart Rhythm Association survey.

Tilz R, Boveda S, Deharo JC, Dobreanu D, Haugaa KH, Dagres N
The aim of this EP Wire was to assess the management, indications, and techniques for implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) device replacement in Europe. A total of 24 centres in 14 European countries completed the questionnaire. All centres were members of the European Heart Rhythm Association Electrophysiology Research Network. Replacement procedures were performed by electrophysiologists in 52% of the centres, by cardiologists in 33%, and both in the remaining centres. In the majority of centres, the procedures were performed during a short hospitalization (<2 days; 61.2%), or on an outpatient basis (28%). The overwhelming majority of centres reported that they replaced ICDs at the end of battery life. Only in a small subset (<10%) of patients with ICD for primary prevention and without ventricular tachycardia (VT) since implantation, ICD was not replaced. In inherited primary arrhythmia syndromes, 80% of the centres always replaced the ICD at the end of battery life. After VT ablation, only few centres (9%) explanted or downgraded the device that was previously implanted for secondary prevention, but only in those patients without new VT episodes. Patient\'s life expectancy <1 year was the most commonly reported reason (61%) to downgrade from a CRT-D to a CRT-P device. While warfarin therapy was continued in 47% of the centres, non-vitamin K oral anticoagulants were discontinued without bridging 24 h prior to replacement procedures in 60%. Finally, in 65% of the centres, VT induction and shock testing during ICD and CRT-D replacement were performed only in the case of leads with a warning or with borderline measurements. This survey provides a snapshot of the perioperative management, indications, and techniques of ICD and CRT device replacement in Europe. It demonstrates some variations between participating centres, probably related to local policies and to the heterogeneity of the ICD population.

Europace: 13 Jun 2016; 18:945-9
Tilz R, Boveda S, Deharo JC, Dobreanu D, Haugaa KH, Dagres N
Europace: 13 Jun 2016; 18:945-9 | PMID: 27297231
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Abstract

The role of the Arrhythmia Team, an integrated, multidisciplinary approach to treatment of patients with cardiac arrhythmias: results of the European Heart Rhythm Association survey.

Fumagalli S, Chen J, Dobreanu D, Madrid AH, Tilz R, Dagres N
Management of patients with cardiac arrhythmias is increasingly complex because of continuous technological advance and multifaceted clinical conditions associated with ageing of the population, the presence of co-morbidities and the need for polypharmacy. The aim of this European Heart Rhythm Association Scientific Initiatives Committee survey was to provide an insight into the role of the Arrhythmia Team, an integrated, multidisciplinary approach to management of patients with cardiac arrhythmias. Forty-eight centres from 18 European countries replied to the Web-based questionnaire. The presence of an Arrhythmia Team was reported by 44% of the respondents, whereas 17% were not familiar with this term. Apart from the electrophysiologist, health professionals who should belong to such teams, according to the majority of the respondents, include a clinical cardiologist, a nurse, a cardiac surgeon, a heart failure specialist, a geneticist, and a geriatrician. Its main activity should be dedicated to the management of patients with complex clinical conditions or refractory or inherited forms of arrhythmias. When present, the Arrhythmia Team was considered helpful by 95% of respondents; the majority of centres (79%) agreed that it should be implemented. The Arrhythmia Team seems to be connected to important expectations in the management of cardiac arrhythmias. The efficacy of such an integrated and multidisciplinary approach should be encouraged and tested in clinical practice.

Europace: 12 May 2016; 18:623-7
Fumagalli S, Chen J, Dobreanu D, Madrid AH, Tilz R, Dagres N
Europace: 12 May 2016; 18:623-7 | PMID: 27174994
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Abstract

Sudden cardiac death in China: current status and future perspectives.

Zhang S
Sudden cardiac death (SCD) is a major cause of mortality worldwide. Similar to the number of SCDs in western countries including the USA, the number of SCDs in China is ∼544 000 annually. However, there are significant differences in patient characteristics between Chinese primary prevention population and U.S. primary prevention population. In contrast to western countries where implantable cardioverter-defibrillator (ICD) devices have been well adopted as a major effective method for both primary and secondary prevention of SCD, China has a low prevalence of ICD utilization (∼1.5 device per 1 million people). Socioeconomic and political factors, awareness and knowledge of SCD, and the difference in disease patterns have led to the underutilization of ICD in China. China, as the most populated and the second largest economic country in the world, has now taken variable approaches to address this pressing health problem and enhances the delivery of lifesaving therapies, including arrhythmia ablation and medical treatment besides ICD, to patients who are at risk of SCD.

Europace: 03 Feb 2016; 17:ii14-ii18
Zhang S
Europace: 03 Feb 2016; 17:ii14-ii18 | PMID: 26842111
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Abstract

Asian strategy for stroke prevention in atrial fibrillation.

Chiang CE, Wang KL, Lin SJ
Atrial fibrillation (AF) has become a major health burden in Asia. It is estimated that in year 2050 Asia will have 72 million AF patients, and 2.9 million among them will suffer from AF-associated stroke. Asian AF patients have similar cardiovascular co-morbidities as westerns, and the recently developed CHA2DS2-VASc score remains valid in predicting stroke risk in Asians, outperforming other scoring systems. There is little evidence supporting a role of aspirin in preventing AF-associated stroke in Asians. Warfarin is effective for the prevention of stroke in Asians, but is very difficult to use. Warfarin-induced bleeding events are more common in Asians. Four major clinical trials have been performed to test non-vitamin K antagonist oral anticoagulants (NOACs) vs. warfarin in the stroke prevention in AF. Warfarin produced higher risk of major bleeding and intra-cranial haemorrhage in Asians compared with those in non-Asians, even though anticoagulation intensity was lower in Asians. All these trials consistently demonstrated that NOACs were superior or non-inferior to warfarin. The benefits of NOACs were especially robust in Asians. The relative risk reduction in most of the efficacy endpoints and the safety endpoints was numerically greater in Asians than in non-Asians. There was no evidence of increased risk of gastro-intestinal bleeding associated with NOACs in Asians. Unless in a few conditions when NOACs are contraindicated, NOACs are preferred medications in the stroke prevention for AF in Asians.

Europace: 03 Feb 2016; 17:ii31-ii39
Chiang CE, Wang KL, Lin SJ
Europace: 03 Feb 2016; 17:ii31-ii39 | PMID: 26842113
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Abstract

Subclinical atrial fibrillation and stroke: insights from continuous monitoring by implanted cardiac electronic devices.

Lau CP, Siu CW, Yiu KH, Lee KL, Chan YH, Tse HF
Nearly one out of five strokes is associated with atrial fibrillation (AF). Atrial fibrillation is often intermittent and asymptomatic. Detection of AF after cryptogenic stroke will likely change therapy from antiplatelet to oral anticoagulation agents for secondary stroke prevention. A critical step is to convert \'covert\' AF into electrocardiogram documented AF. External rhythm recording devices have registered a high incidence of AF to occur after a cryptogenic stroke, but are limited by short duration of continuous recordings. Invasive cardiac monitoring using insertable leadless cardiac monitors are sensitive means to identify subclinical AF (SCAF) after cryptogenic stroke, and AF has been reported to occur in 8.9% of these patients by 6 months in one study. It will be more attractive to identify SCAF before a stroke occurs. Recent series in pacemaker and implantable cardioverter-defibrillator (ICD) recipients showed that short episodes of SCAF increased stroke risk, with odds ratio ∼2.2-3.1 compared with those without SCAF recorded. However, temporal sequence of recorded SCAF and stroke occurrence was uncertain, and the overall stroke risk was lower compared with patients with clinical AF at similar risk scores. This article reviews the incidence and clinical role of using implanted devices to detect SCAF and discusses the implication of SCAF so detected in primary and secondary stroke prevention.

Europace: 03 Feb 2016; 17:ii40-ii46
Lau CP, Siu CW, Yiu KH, Lee KL, Chan YH, Tse HF
Europace: 03 Feb 2016; 17:ii40-ii46 | PMID: 26842114
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Abstract

Catheter ablation of atrial fibrillation in chronic heart failure: state-of-the-art and future perspectives.

Anselmino M, Matta M, Castagno D, Giustetto C, Gaita F
Catheter ablation of atrial fibrillation (AFCA) is a widely recommended treatment for symptomatic atrial fibrillation (AF) patients refractory to pharmacological treatment. Catheter ablation of AF is becoming a therapeutic option also among patients with chronic heart failure (CHF), on top of optimal medical treatment, being this arrhythmia related to a higher risk of death and/or symptom\'s worsening. In fact, in this setting, clinical evidences are continuously increasing. The present systematic review pools all published experiences concerning AFCA among CHF patients, or patients with structural cardiomyopathies, in order to summarize procedural safety and efficacy in this specific population. Moreover, the effects of AFCA on functional class and quality of life and the different procedural protocols available are discussed. The present work, therefore, attempts to provide an evidence-based clinical perspective to optimize clinical indication and tailor procedural characteristics and endpoints to patients affected by CHF referred for AFCA.

Europace: 08 Feb 2016; epub ahead of print
Anselmino M, Matta M, Castagno D, Giustetto C, Gaita F
Europace: 08 Feb 2016; epub ahead of print | PMID: 26857188
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Abstract

Atrial fibrillation patients do not benefit from acetylsalicylic acid.

Själander S, Själander A, Svensson PJ, Friberg L
Oral anticoagulation is the recommended treatment for stroke prevention in patients with atrial fibrillation. Notwithstanding, many patients are treated with acetylsalicylic acid (ASA) as monotherapy. Our objective was to investigate if atrial fibrillation patients benefit from ASA as monotherapy for stroke prevention.Methods and results: Retrospective study of patients with a clinical diagnosis of atrial fibrillation between 1 July 2005 and 1 January 2009 in the National Swedish Patient register, matched with data from the National Prescribed Drugs register. Endpoints were ischaemic stroke, thrombo-embolic event, intracranial haemorrhage, and major bleeding. The study population consisted of 115 185 patients with atrial fibrillation, of whom 58 671 were treated with ASA as monotherapy and 56 514 were without any antithrombotic treatment at baseline. Mean follow-up was 1.5 years. Treatment with ASA was associated with higher risk of ischaemic stroke and thrombo-embolic events compared with no antithrombotic treatment.Conclusion: Acetylsalicylic acid as monotherapy in stroke prevention of atrial fibrillation has no discernable protective effect against stroke, and may even increase the risk of ischaemic stroke in elderly patients. Thus, our data support the new European guidelines recommendation that ASA as monotherapy should not be used as stroke prevention in atrial fibrillation.

Europace: 24 Oct 2013; epub ahead of print
Själander S, Själander A, Svensson PJ, Friberg L
Europace: 24 Oct 2013; epub ahead of print | PMID: 24158253
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Abstract

Heart failure due to right ventricular apical pacing: the importance of flow patterns.

Cicchitti V, Radico F, Bianco F, Gallina S, Tonti G, De Caterina R
In patients receiving permanent cardiac electrical stimulation, a high burden of apical right ventricular pacing is associated with an increased incidence of heart failure. Despite the large body of electrocardiographic, echocardiographic, and pathological data, mechanisms underlying this serious complication are not fully understood. Moreover, the empirical use of alternative right ventricular pacing sites, both in the experimental and in the clinical setting, has not provided better results in terms of clinical outcome. Recent data derived by echocardiographic particle image velocimetry of intracardiac flows have shown abnormal flow patterns in patients with dyssynchrony of left ventricular wall contraction, and the reversion to normal flow dynamics after successful electrical cardiac resynchronization therapy. This suggests that a normal intraventricular flow pattern is strongly dependent on the highly coordinated contraction of the ventricular wall segments and that an abnormal sequence of wall contraction may trigger the development of overt heart failure. This review summarizes the state of the art on this topic, highlighting postulated underlying basic mechanisms linking abnormal flow with the development of pacing-induced heart failure. This research line suggests the importance of studying intraventricular fluid dynamics as a new powerful tool for a more complete understanding of mechanisms involved, and ultimately to prevent pacing-related heart failure.

Europace: 31 May 2016; epub ahead of print
Cicchitti V, Radico F, Bianco F, Gallina S, Tonti G, De Caterina R
Europace: 31 May 2016; epub ahead of print | PMID: 27247008
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Abstract

The role of valvular regurgitation in catheter ablation outcomes of patients with long-standing persistent atrial fibrillation.

Zhao L, Jiang W, Zhou L, Gu J, ... Wu S, Liu X
The role of valvular regurgitation (VR) in outcomes of patients obtaining current ablation endpoints with long-standing persistent atrial fibrillation (LS-AF) was evaluated.Methods and results: In all, 216 consecutive patients obtaining current ablation endpoints with LS-AF were studied. A standard two-dimensional and Doppler transthoracic echocardiography (TTE) was performed in every patient before the procedure. The presentation and the grade of mitral regurgitation (MR), tricuspid regurgitation, and aortic regurgitation were evaluated. The clinical characteristics, TTE, and procedural characteristics were compared between the sinus rhythm group and the recurrent atrial tachyarrhythmia (ATa) group. After a follow-up of 18.9 ± 2.7 months, there were 48 patients in the ATa group. The patients in the ATa group had greater MR, longer AF duration, and larger left atrium (LA). In multivariate analyses, MR, LA size, and AF duration were independent predictors of recurrent ATa. The grades of MR severity were correlated with the rate of recurrent ATa, and more severe grade of MR indicated more recurrent ATa. Compared with the patients with organic MR, the patients with functional MR had a lower rate of recurrent ATa and lesser degrees of MR.Conclusion: In the three types of VR, MR was associated with recurrent ATa after AF ablation. Patients with ATa recurrence had more severe MR and greater organic MR.

Europace: 27 Oct 2013; epub ahead of print
Zhao L, Jiang W, Zhou L, Gu J, ... Wu S, Liu X
Europace: 27 Oct 2013; epub ahead of print | PMID: 24163415
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Abstract

Long-term results of pulmonary vein antrum isolation in patients with atrial fibrillation: an analysis in regards to substrates and pulmonary vein reconnections.

Yamaguchi T, Tsuchiya T, Nagamoto Y, Miyamoto K, ... Okishige K, Takahashi N
To examine the impact of left atrial (LA) low-voltage zones (LVZs) on atrial fibrillation (AF) recurrence after pulmonary vein antrum isolation (PVAI) without LA substrate modification.Methods and results: Seventy-six patients with AF (paroxysmal/persistent 65/11) were prospectively enroled. Left atrial voltage maps were constructed during sinus rhythm using NavX to identify LVZs (<0.5 mV), and PVAI without any LA substrate modification was performed using an open-irrigation catheter. After PVAI, 20 mg of adenosine triphosphate (ATP) was injected. Adenosine triphosphate-induced PV reconnections were eliminated by touch-up ablation when unmasked. Voltage maps revealed LVZs in 24 patients (32%) and no LVZs in 52 (68%). During 24 ± 7 months of follow-up, 15 patients (63%) with LVZs and 10 (19%) without had AF recurrences off antiarrhythmic drugs (log-rank P < 0.001). A multivariate logistic regression analysis revealed that LVZ areas [odds ratio (OR): 1.12 per 1 cm(2), 95% confidence interval (CI): 1.04-1.23, P = 0.001] and ATP-induced reconnection (OR: 2.08, 95% CI: 1.01-4.91, P = 0.046) were significant predictors of recurrence. In those with LVZs, the LVZ area was strongly correlated with the LA body volume (r = 0.81, P < 0.001) and a unique predictor of recurrence (OR: 1.17 per 1 cm(2), 95% CI: 1.01-1.55, P = 0.031), while in those without an LVZ, ATP-induced PV reconnection was a unique predictor (OR: 3.24, 95% CI: 1.15-15.39, P = 0.025).Conclusion: The LVZ area was an independent predictor of recurrence after PVAI without any LA substrate modification. Adenosine triphosphate-induced PV reconnection was also an independent predictor, especially in those without LVZs.

Europace: 29 Sep 2013; epub ahead of print
Yamaguchi T, Tsuchiya T, Nagamoto Y, Miyamoto K, ... Okishige K, Takahashi N
Europace: 29 Sep 2013; epub ahead of print | PMID: 24078342
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Abstract

Perioperative management of antithrombotic treatment during implantation or revision of cardiac implantable electronic devices: the European Snapshot Survey on Procedural Routines for Electronic Device Implantation (ESS-PREDI).

Deharo JC, Sciaraffia E, Leclercq C, Amara W, ... Blomström-Lundqvist C, Coordinated by the Scientific Initiatives Committee of the European Heart Rhythm Association
The European Snapshot Survey on Procedural Routines for Electronic Device Implantation (ESS-PREDI) was a prospective European survey of consecutive adults who had undergone implantation/surgical revision of a cardiac implantable electronic device (CIED) on chronic antithrombotic therapy (enrolment March-June 2015). The aim of the survey was to investigate perioperative treatment with oral anticoagulants and antiplatelets in CIED implantation or surgical revision and to determine the incidence of complications, including clinically significant pocket haematomas. Information on antithrombotic therapy before and after surgery and bleeding and thromboembolic complications occurring after the intervention was collected at first follow-up. The study population comprised 723 patients (66.7% men, 76.9% aged ≥66 years). Antithrombotic treatment was continued during surgery in 489 (67.6%) patients; 6 (0.8%) had their treatment definitively stopped; 46 (6.4%) were switched to another antithrombotic therapy. Heparin bridging was used in 55 out of 154 (35.8%) patients when interrupting vitamin K antagonist (VKA) treatment. Non-vitamin K oral anticoagulant (NOAC) treatment was interrupted in 88.7% of patients, with heparin bridging in 25.6%, but accounted for only 25.3% of the oral anticoagulants used. A total of 108 complications were observed in 98 patients. No intracranial haemorrhage or embolic events were observed. Chronic NOAC treatment before surgery was associated with lower rates of minor pocket haematoma (1.4%; P= 0.042) vs. dual antiplatelet therapy (13.0%), VKA (11.4%), VKA + antiplatelet (9.2%), or NOAC + antiplatelet (7.7%). Similar results were observed for bleeding complications (P= 0.028). Perioperative management of patients undergoing CIED implantation/surgical revision while on chronic antithrombotic therapy varies, with evidence of a disparity between guideline recommendations and practice patterns in Europe. Haemorrhagic complications were significantly less frequent in patients treated with NOACs. Despite this, the incidence of severe pocket haematomas was low.

Europace: 25 May 2016; 18:778-84
Deharo JC, Sciaraffia E, Leclercq C, Amara W, ... Blomström-Lundqvist C, Coordinated by the Scientific Initiatives Committee of the European Heart Rhythm Association
Europace: 25 May 2016; 18:778-84 | PMID: 27226497
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Abstract

The role of myocardial wall thickness in atrial arrhythmogenesis.

Whitaker J, Rajani R, Chubb H, Gabrawi M, ... Niederer S, O\'Neill MD
Changes in the structure and electrical behaviour of the left atrium are known to occur with conditions that predispose to atrial fibrillation (AF) and in response to prolonged periods of AF. We review the evidence that changes in myocardial thickness in the left atrium are an important part of this pathological remodelling process. Autopsy studies have demonstrated changes in the thickness of the atrial wall between patients with different clinical histories. Comparison of the reported tissue dimensions from pathological studies provides an indication of normal ranges for atrial wall thickness. Imaging studies, most commonly done using cardiac computed tomography, have demonstrated that these changes may be identified non-invasively. Experimental evidence using isolated tissue preparations, animal models of AF, and computer simulations proves that the three-dimensional tissue structure will be an important determinant of the electrical behaviour of atrial tissue. Accurately identifying the thickness of the atrial may have an important role in the non-invasive assessment of atrial structure. In combination with atrial tissue characterization, a comprehensive assessment of the atrial dimensions may allow prediction of atrial electrophysiological behaviour and in the future, guide radiofrequency delivery in regions based on their tissue thickness.

Europace: 31 May 2016; epub ahead of print
Whitaker J, Rajani R, Chubb H, Gabrawi M, ... Niederer S, O'Neill MD
Europace: 31 May 2016; epub ahead of print | PMID: 27247007
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Abstract

Efficacy and safety of rivaroxaban compared with vitamin K antagonists for peri-procedural anticoagulation in catheter ablation of atrial fibrillation: a systematic review and meta-analysis.

Vamos M, Cappato R, Marchlinski FE, Natale A, Hohnloser SH
Rivaroxaban is increasingly used in patients undergoing catheter ablation of atrial fibrillation (AF). In the absence of large controlled trials, a comprehensive meta-analysis of the literature appears to be the best way to obtain reliable evidence on rare peri-procedural outcomes such as thromboembolic or bleeding events. We aimed to provide a detailed analysis of currently available data on safety and efficacy of peri-procedural rivaroxaban in patients undergoing AF ablation. We performed a systematic search of the English language literature for studies comparing peri-procedural rivaroxaban therapy with vitamin K antagonists (VKAs) and reporting detailed data on bleeding and/or thromboembolic complications. The Peto odds ratio (POR) was used to pool data into a fixed-effect meta-analysis. A total of 7400 patients undergoing catheter ablation were included in 15 observational and 1 randomized studies of which 1994 were receiving rivaroxaban and 5406 VKA. The risk of thromboembolism trended to be lower in the rivaroxaban group [4/1954 vs. 19/5219, POR 0.40, 95% confidence interval (CI), 0.16-1.01, P = 0.052]. Major bleeding events occurred in 23 of 1994 cases (1.15%) in the rivaroxaban and 90 of 5406 (1.66%) in the VKA group (POR 0.74, 95% CI, 0.46-1.21, P = 0.23). A total of 87 minor bleeding events were reported in 1753 patients (4.96%) in the rivaroxaban group and in 165 of 4009 patients (4.12%) in the VKA group (POR 0.84, 95% CI 0.63-1.11, p = 0.22). In patients undergoing AF ablation, rivaroxaban appears to be an effective and safe alternative to VKA.

Europace: 21 Jan 2016; epub ahead of print
Vamos M, Cappato R, Marchlinski FE, Natale A, Hohnloser SH
Europace: 21 Jan 2016; epub ahead of print | PMID: 26797248
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Abstract

Management of atrial fibrillation in patients with chronic kidney disease in Europe Results of the European Heart Rhythm Association Survey.

Potpara TS, Lenarczyk R, Larsen TB, Deharo JC, ... European Heart Rhythm Association, Conducted by the Scientific Initiatives Committee European Heart Rhythm Association
The purpose of this European Heart Rhythm (EHRA) Scientific Initiatives Committee EP Wire Survey was to assess \'real-world\' practice in the management of patients with atrial fibrillation (AF) and chronic kidney disease (CKD) in the European Eelectrophysiology centres. Of 41 responding centres, 39 (95.1%) and 37 (90.2%) routinely evaluated renal function in AF patients at first presentation and during follow-up, respectively, but 13 centres (31.7%) re-assessed advanced CKD only at ≥1-year intervals. While the use of oral anticoagulants (OACs) in mild-to-moderate CKD patients was mostly guided by individual patient stroke risk, 31% of the centres used no therapy, or aspirin or the left appendage occlusion in patients with advanced CKD and HAS-BLED ≥ 3. Vitamin K antagonists (VKAs) were preferred in patients with severe CKD or under renal replacement therapy (RRT), any non-VKA in patients with mild CKD, and apixaban in patients with moderate CKD. Rhythm control was preferred in patients with mild-to-moderate CKD (48.7% of centres), and rate control in patients with severe CKD (51.2% of centres). In 20 centres (48.8%), AF ablation was not performed in advanced CKD patients. Most centres performed AF ablation on OAC, but heparin bridging was still used in >10% of centres. Our survey has shown that the importance of renal function monitoring in AF patients is well recognized in clinical practice. In patients with mild-to-moderate CKD, AF is mostly managed according to the guideline recommendations, but more data are needed to guide the management of AF in patients with severe CKD or RRT.

Europace: 05 Jan 2016; 17:1862-7
Potpara TS, Lenarczyk R, Larsen TB, Deharo JC, ... European Heart Rhythm Association, Conducted by the Scientific Initiatives Committee European Heart Rhythm Association
Europace: 05 Jan 2016; 17:1862-7 | PMID: 26733617
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Abstract

Current ablation techniques for persistent atrial fibrillation: results of the European Heart Rhythm Association Survey.

Dagres N, Bongiorni MG, Larsen TB, Hernandez-Madrid A, ... European Heart Rhythm Association, Conducted by the Scientific Initiatives Committee European Heart Rhythm Association
The aim of this survey was to provide insight into current practice regarding ablation of persistent atrial fibrillation (AF) among members of the European Heart Rhythm Association electrophysiology research network. Thirty centres responded to the survey. The main ablation technique for first-time ablation was stand-alone pulmonary vein isolation (PVI): in 67% of the centres for persistent but not long-standing AF and in 37% of the centres for long-standing persistent AF as well. Other applied techniques were ablation of fractionated electrograms, placement of linear lesions, stepwise approach until AF termination, and substrate mapping and isolation of low-voltage areas. However, the percentage of centres applying these techniques during first ablation did not exceed 25% for any technique. When stand-alone PVI was performed in patients with persistent but not long-standing AF, the majority (80%) of the centres used an irrigated radiofrequency ablation catheter whereas 20% of the respondents used the cryoballoon. Similar results were reported for ablation of long-standing persistent AF (radiofrequency 90%, cryoballoon 10%). Neither rotor mapping nor one-shot ablation tools were used as the main first-time ablation methods. Systematic search for non-pulmonary vein triggers was performed only in 10% of the centres. Most common 1-year success rate off antiarrhythmic drugs was 50-60%. Only 27% of the centres knew their 5-year results. In conclusion, patients with persistent AF represent a significant proportion of AF patients undergoing ablation. There is a shift towards stand-alone PVI being the primary choice in many centres for first-time ablation in these patients. The wide variation in the use of additional techniques and in the choice of endpoints reflects the uncertainties and lack of guidance regarding the most optimal approach. Procedural success rates are modest and long-term outcomes are unknown in most centres.

Europace: 26 Oct 2015; 17:1596-600
Dagres N, Bongiorni MG, Larsen TB, Hernandez-Madrid A, ... European Heart Rhythm Association, Conducted by the Scientific Initiatives Committee European Heart Rhythm Association
Europace: 26 Oct 2015; 17:1596-600 | PMID: 26498718
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Abstract

Is modification of the VVI backup mode in implantable cardioverter-defibrillators from St Jude medical required due to increased risk of inappropriate shocks?

Philbert BT, Tfelt-Hansen J, Jacobsen PK, Pehrson S, ... Jøns C, Petersen HH
Inappropriate implantable cardioverter-defibrillator (ICD) shock therapy is painful, stressful, and typically occurs unexpected in conscious patients and may be related to a less favourable prognosis. In our institution, we have observed four cases of multiple inappropriate ICD shocks during reset to VVI backup mode. All four patients were implanted with a St Jude Medical ICD since 2010. The reset to VVI backup mode happens as a \'safety\' response when the ICD encounters errors in the software or hardware often due to electromagnetic interference. The ICD then operates in a simple mode, with only a ventricular fibrillation (VF) zone starting at 146 b.p.m., with shock therapy only and changes in sensitivity settings making the ICD more sensitive. In all cases, the reason for the multiple inappropriate shocks was that the VF zone was reached due to exercise-induced sinus tachycardia or due to oversensing during sinus rhythm. The VVI backup mode has to balance between protection from failure of ICD therapy during life-threatening ventricular arrhythmias and from inappropriate shocks. It seems the non-programmable parameters in VVI backup mode of St Jude Medical ICDs carry an unacceptable high risk of inappropriate shocks during normal rhythm as illustrated by our four cases. A higher VF zone comparable with the zones chosen by the other manufacturer would give a better balance, since it is very unlikely that a patient will need shock therapy urgently for slow ventricular tachycardia.

Europace: 31 May 2016; epub ahead of print
Philbert BT, Tfelt-Hansen J, Jacobsen PK, Pehrson S, ... Jøns C, Petersen HH
Europace: 31 May 2016; epub ahead of print | PMID: 27247013
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Abstract

Arrhythmogenic right ventricular cardiomyopathy, clinical manifestations, and diagnosis.

Haugaa KH, Haland TF, Leren IS, Saberniak J, Edvardsen T
This review aims to give an update on the pathogenesis, clinical manifestations, and diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC). Arrhythmogenic right ventricular cardiomyopathy is mainly an autosomal dominant inherited disease linked to mutations in genes encoding desmosomes or desmosome-related proteins. Classic symptoms include palpitations, cardiac syncope, and aborted cardiac arrest due to ventricular arrhythmias. Heart failure may develop in later stages. Diagnosis is based on the presence of major and minor criteria from the Task Force Criteria revised in 2010 (TFC 2010), which includes evaluation of findings from six different diagnostic categories. Based on this, patients are classified as having possible, borderline, or definite ARVC. Imaging is important in ARVC diagnosis, including both echocardiography and cardiac magnetic resonance imaging for detecting structural and functional abnormalities, but importantly these findings may occur after electrical alterations and ventricular arrhythmias. Electrocardiograms (ECGs) and signal-averaged ECGs are analysed for depolarization and repolarization abnormalities, including T-wave inversions as the most common ECG alteration. Ventricular arrhythmias are common in ARVC and are considered a major diagnostic criterion if originating from the RV inferior wall or apex. Family history of ARVC and detection of an ARVC-related mutation are included in the TFC 2010 and emphasize the importance of family screening. Electrophysiological studies are not included in the diagnostic criteria, but may be important for differential diagnosis including RV outflow tract tachycardia. Further differential diagnoses include sarcoidosis, congenital abnormalities, myocarditis, pulmonary hypertension, dilated cardiomyopathy, and athletic cardiac adaptation, which may mimic ARVC.

Europace: 25 Oct 2015; epub ahead of print
Haugaa KH, Haland TF, Leren IS, Saberniak J, Edvardsen T
Europace: 25 Oct 2015; epub ahead of print | PMID: 26498164
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Abstract

Atrial fibrillation and gastroesophageal reflux disease: the cardiogastric interaction.

Linz D, Hohl M, Vollmar J, Ukena C, Mahfoud F, Böhm M
Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with significant morbidity and mortality. Multiple conditions like hypertension, heart failure, diabetes, sleep apnoea, and obesity play a role for the initiation and perpetuation of AF. Recently, a potential association between gastroesophageal reflux disease (GERD) and AF development has been proposed due to the close anatomic vicinity of the oesophagus and the left atrium. As an understanding of the association between acid reflux disease and AF may be important in the global multimodal treatment strategy to further improve outcomes in a subset of patients with AF, we discuss potential atrial arrhythmogenic mechanisms in patients with GERD, such as gastric and subsequent systemic inflammation, impaired autonomic stimulation, mechanical irritation due to anatomical proximity of the left atrium and the oesophagus, as well as common comorbidities like obesity and sleep-disordered breathing. Data on GERD and oesophageal lesions after AF-ablation procedures will be reviewed. Treatment of GERD to avoid AF or to reduce AF burden might represent a future treatment perspective but needs to be scrutinized in prospective trials.

Europace: 31 May 2016; epub ahead of print
Linz D, Hohl M, Vollmar J, Ukena C, Mahfoud F, Böhm M
Europace: 31 May 2016; epub ahead of print | PMID: 27247004
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Abstract

A comparison of electrocardiographic imaging based on two source types.

van Oosterom A
The aim of the study to compare the performance of two major source types involved in the imaging of the electric activity of the heart on the basis of potential differences observed on the thorax. The images depict either the timing of activation and repolarization of the myocardium or the potential field on a surface closely encompassing the myocardium. The depolarization and repolarization timing on a closed surface bounding the ventricular myocardium was derived from measured body surface potentials (BSPs), an MRI-based electric volume conductor model comprising the geometry of thorax, lungs, heart surface Sh, and cavities. The solution was constrained by using a template of the local transmembrane potentials (TMPs). The latter serve as the strength of the Equivalent Double Layer (EDL) source model (SM), which was used to compute the potential field on Sh (epicardium and endocardium). The second SM is the potential distribution on the epicardium Sp, referred to here as the Equivalent Potential Distribution (EPD). Its strength was estimated directly from the BSPs. The inflection points of the estimated electrograms (ELGs) were taken as markers of the timing of local depolarization and repolarization. The endocardial potential fields estimated using both sources exhibited qualitative similarity, as did the ELGs. With reference to the one generated by the EDL source, the magnitude of the estimated endocardial EPD field was smaller, the downslopes of the ELGs were lower. The timing of depolarization estimated from the EDL-based ELGs was highly correlated with those of the TMP templates, the EPD-based correlation was lower. For the repolarization timing the corresponding test values indicated an insufficient similarity. The EDL- and EPD-based source variants deserve to be studied alongside each other in the future development of electrocardiographic imaging.

Europace: 31 Oct 2014; 16:iv120-iv128
van Oosterom A
Europace: 31 Oct 2014; 16:iv120-iv128 | PMID: 25362162
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Abstract

A roadmap to improve the quality of atrial fibrillation management: proceedings from the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference.

Kirchhof P, Breithardt G, Bax J, Benninger G, ... Lip GY, Camm AJ
At least 30 million people worldwide carry a diagnosis of atrial fibrillation (AF), and many more suffer from undiagnosed, subclinical, or \'silent\' AF. Atrial fibrillation-related cardiovascular mortality and morbidity, including cardiovascular deaths, heart failure, stroke, and hospitalizations, remain unacceptably high, even when evidence-based therapies such as anticoagulation and rate control are used. Furthermore, it is still necessary to define how best to prevent AF, largely due to a lack of clinical measures that would allow identification of treatable causes of AF in any given patient. Hence, there are important unmet clinical and research needs in the evaluation and management of AF patients. The ensuing needs and opportunities for improving the quality of AF care were discussed during the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference in Nice, France, on 22 and 23 January 2015. Here, we report the outcome of this conference, with a focus on (i) learning from our \'neighbours\' to improve AF care, (ii) patient-centred approaches to AF management, (iii) structured care of AF patients, (iv) improving the quality of AF treatment, and (v) personalization of AF management. This report ends with a list of priorities for research in AF patients.

Europace: 19 Oct 2015; epub ahead of print
Kirchhof P, Breithardt G, Bax J, Benninger G, ... Lip GY, Camm AJ
Europace: 19 Oct 2015; epub ahead of print | PMID: 26481149
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Abstract

How are arrhythmias detected by implanted cardiac devices managed in Europe? Results of the European Heart Rhythm Association Survey.

Todd D, Hernandez-Madrid A, Proclemer A, Bongiorni MG, ... European Heart Rhythm Association, Scientific Initiative Committee European Heart Rhythm Association
The management of arrhythmias detected by implantable cardiac devices can be challenging. There are no formal international guidelines to inform decision-making. The purpose of this European Heart Rhythm Association (EHRA) survey was to assess the management of various clinical scenarios among members of the EHRA electrophysiology research network. There were 49 responses to the questionnaire. The survey responses were mainly (81%) from medium-high volume device implanting centres, performing more than 200 total device implants per year. Clinical scenarios were described focusing on four key areas: the implantation of pacemakers for bradyarrhythmia detected on an implantable loop recorder (ILR), the management of patients with ventricular arrhythmia detected by an ILR or pacemaker, the management of atrial fibrillation in patients with pacemakers and cardiac resynchronization therapy devices and the management of ventricular tachycardia in patients with implantable cardioverter-defibrillators.

Europace: 06 Oct 2015; 17:1449-53
Todd D, Hernandez-Madrid A, Proclemer A, Bongiorni MG, ... European Heart Rhythm Association, Scientific Initiative Committee European Heart Rhythm Association
Europace: 06 Oct 2015; 17:1449-53 | PMID: 26443791
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Abstract

Non-vitamin K antagonist oral anticoagulants in atrial fibrillation accompanying mitral stenosis: the concept for a trial.

De Caterina R, John Camm A
Patients at thromboembolic risk with non-valvular atrial fibrillation (AF) can now be managed either with a vitamin K antagonist (VKA) or with a fixed dose of a non-VKA oral anticoagulant (NOAC), while patients with valvular AF have been restricted to VKAs on the basis of a potentially higher risk and different mechanism of thrombosis, and the lack of sufficient data on the efficacy of NOACs. The terms \'non-valvular AF\' and \'valvular AF\' have not been however consistently defined. \'Valvular\' AF has included any valvular disorder, including valve replacement and repair. In AF with rheumatic mitral disease, observational studies strongly suggest that VKA treatment is valuable. These patients have not been included in NOAC trials, but there is also no stringent argument to have excluded them. This is at sharp variance from patients with mechanical valves, also excluded from the pivotal Phase III trial comparing warfarin with NOACs, but in whom a single Phase II trial of dabigatran etexilate against VKA treatment was stopped prematurely because of increased rates of thromboembolism as well as increased bleeding associated with dabigatran. Until more data are available, such patients should be therefore managed with VKAs. We here propose an open-label randomized trial of one of the NOACs against the best of treatment available in regions of the world in which rheumatic heart disease is still highly prevalent, aiming at showing the superiority of the NOAC used against current standard treatment.

Europace: 08 Oct 2015; epub ahead of print
De Caterina R, John Camm A
Europace: 08 Oct 2015; epub ahead of print | PMID: 26450845
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Abstract

Catheter ablation for atrial fibrillation: results from the first European Snapshot Survey on Procedural Routines for Atrial Fibrillation Ablation (ESS-PRAFA) Part II.

Chen J, Dagres N, Hocini M, Fauchier L, ... Conducted by the Scientific Initiatives Committee of the European Heart Rhythm Association (EHRA), Conducted by the Scientific Initiatives Committee of the European Heart Rhythm Association EHRA
The European Snapshot Survey on Procedural Routines in Atrial Fibrillation Ablation (ESS-PRAFA) is a prospective, multicentre snapshot survey collecting patient-based data on current clinical practices during atrial fibrillation (AF) ablation. The participating centres were asked to prospectively enrol consecutive patients during a 6-week period (from September to October 2014). A web-based case report form was employed to collect information of patients and data of procedures. A total of 455 eligible consecutive patients from 13 countries were enrolled (mean age 59 ± 10.8 years, 28.8% women). Distinct strategies and endpoints were collected for AF ablation procedures. Pulmonary vein isolation (PVI) was performed in 96.7% and served as the endpoint in 91.3% of procedures. A total of 52 (11.5%) patients underwent ablation as first-line therapy. The cryoballoon technique was employed in 31.4% of procedures. Procedure, ablation, and fluoroscopy times differed among various types of AF ablation. Divergences in patient selection and complications were observed among low-, medium-, and high-volume centres. Adverse events were observed in 4.6% of AF ablation procedures. In conclusion, PVI was still the main strategy for AF ablation. Procedure-related complications seemed not to have declined. The centre volume played an important role in patient selection, strategy choice, and had impact on the rate of periprocedural complication.

Europace: 13 Oct 2015; epub ahead of print
Chen J, Dagres N, Hocini M, Fauchier L, ... Conducted by the Scientific Initiatives Committee of the European Heart Rhythm Association (EHRA), Conducted by the Scientific Initiatives Committee of the European Heart Rhythm Association EHRA
Europace: 13 Oct 2015; epub ahead of print | PMID: 26462700
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Abstract

Battery longevity in cardiac resynchronization therapy implantable cardioverter defibrillators.

Alam MB, Munir MB, Rattan R, Flanigan S, ... Jain S, Saba S
Cardiac resynchronization therapy (CRT) implantable cardioverter defibrillators (ICDs) deliver high burden ventricular pacing to heart failure patients, which has a significant effect on battery longevity. The aim of this study was to investigate whether battery longevity is comparable for CRT-ICDs from different manufacturers in a contemporary cohort of patients.Methods and results: All the CRT-ICDs implanted at our institution from 1 January 2008 to 31 December 2010 were included in this analysis. Baseline demographic and clinical data were collected on all patients using the electronic medical record. Detailed device information was collected on all patients from scanned device printouts obtained during routine follow-up. The primary endpoint was device replacement for battery reaching the elective replacement indicator (ERI). A total of 646 patients (age 69 ± 13 years), implanted with CRT-ICDs (Boston Scientific 173, Medtronic 416, and St Jude Medical 57) were included in this analysis. During 2.7 ± 1.5 years follow-up, 113 (17%) devices had reached ERI (Boston scientific 4%, Medtronic 25%, and St Jude Medical 7%, P < 0.001). The 4-year survival rate of device battery was significantly worse for Medtronic devices compared with devices from other manufacturers (94% for Boston scientific, 67% for Medtronic, and 92% for St Jude Medical, P < 0.001). The difference in battery longevity by manufacturer was independent of pacing burden, lead parameters, and burden of ICD therapy.Conclusion: There are significant discrepancies in CRT-ICD battery longevity by manufacturer. These data have important implications on clinical practice and patient outcomes.

Europace: 07 Oct 2013; epub ahead of print
Alam MB, Munir MB, Rattan R, Flanigan S, ... Jain S, Saba S
Europace: 07 Oct 2013; epub ahead of print | PMID: 24099864
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Abstract

Human cardiac systems electrophysiology and arrhythmogenesis: iteration of experiment and computation.

Holzem KM, Madden EJ, Efimov IR
Human cardiac electrophysiology (EP) is a unique system for computational modelling at multiple scales. Due to the complexity of the cardiac excitation sequence, coordinated activity must occur from the single channel to the entire myocardial syncytium. Thus, sophisticated computational algorithms have been developed to investigate cardiac EP at the level of ion channels, cardiomyocytes, multicellular tissues, and the whole heart. Although understanding of each functional level will ultimately be important to thoroughly understand mechanisms of physiology and disease, cardiac arrhythmias are expressly the product of cardiac tissue-containing enough cardiomyocytes to sustain a reentrant loop of activation. In addition, several properties of cardiac cellular EP, that are critical for arrhythmogenesis, are significantly altered by cell-to-cell coupling. However, relevant human cardiac EP data, upon which to develop or validate models at all scales, has been lacking. Thus, over several years, we have developed a paradigm for multiscale human heart physiology investigation and have recovered and studied over 300 human hearts. We have generated a rich experimental dataset, from which we better understand mechanisms of arrhythmia in human and can improve models of human cardiac EP. In addition, in collaboration with computational physiologists, we are developing a database for the deposition of human heart experimental data, including thorough experimental documentation. We anticipate that accessibility to this human heart dataset will further human EP computational investigations, as well as encourage greater data transparency within the field of cardiac EP.

Europace: 31 Oct 2014; 16:iv77-iv85
Holzem KM, Madden EJ, Efimov IR
Europace: 31 Oct 2014; 16:iv77-iv85 | PMID: 25362174
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Abstract

Do cardiologists follow the European guidelines for cardiac pacing and resynchronization therapy? Results of the European Heart Rhythm Association survey.

Sciaraffia E, Dagres N, Hernandez-Madrid A, Proclemer A, Todd D, Blomström-Lundqvist C
The purpose of this European Heart Rhythm Association (EHRA) EP wire survey was to evaluate the implementation of the current guidelines for cardiac pacing and cardiac resynchronization therapy (CRT) in Europe. A total of 48 centres replied to the survey, 34 of them (71%) were university hospitals. All responding centres implement CRT in patients with classical indications, i.e. sinus rhythm, New York Heart Association (NYHA) functional class II, III, or ambulatory IV, left ventricular ejection fraction (LVEF) 35%, and left bundle-branch block (LBBB) with QRS duration >150 ms, while 31 centres (67%) would implant a CRT device in patients with the same characteristics but with a non-LBBB pattern. Forty-one centres (89%) would also implant CRT in patients with sinus rhythm, NYHA Class II, III, or ambulatory IV, LVEF <35%, and LBBB with QRS duration between 120 and 150 ms, while only eight centres (17%) would implant the device in patients with the same characteristics but with a non-LBBB pattern. In patients with LVEF <35% and QRS duration below 120 ms, the majority of the centres (80%) would implant a single- or dual-chamber implantable cardioverter-defibrillator, but in nine cases (20%) no device was considered to be indicated. The results of this survey showed a good adherence to some of the current recommendations. Still some reluctance exists when offering the device therapy to patients with QRS duration in the lower range.

Europace: 31 Dec 2014; 17:148-51
Sciaraffia E, Dagres N, Hernandez-Madrid A, Proclemer A, Todd D, Blomström-Lundqvist C
Europace: 31 Dec 2014; 17:148-51 | PMID: 25552672
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Abstract

Atrial fibrillatory rate in the clinical context: natural course and prediction of intervention outcome.

Platonov PG, Corino VD, Seifert M, Holmqvist F, Sörnmo L
Shortening of atrial refractory period during atrial fibrillation has been considered a hallmark of atrial electrical remodelling. The atrial fibrillatory cycle length, which is intimately related to the atrial fibrillatory rate (AFR), is generally accepted as a surrogate marker for local refractoriness. The value of using AFR to monitor the progress of atrial ablation therapy has been demonstrated and gradual slowing of AFR has consistently been observed to precede arrhythmia termination during paroxysmal or permanent atrial fibrillation ablation. Today, AFR is the key characteristic of the fibrillatory process, repeatedly validated against intracardiac recordings and extensively studied in clinical contexts. This paper provides an overview of clinical data accumulated since the method was introduced in 1998, and to present the current state of knowledge regarding ECG-derived AFR: its time course and dynamics, clinical factors affecting AFR, and available evidence of its value in the clinical context. We conclude that AFR is a promising, easily available AF characteristic that can be derived from the conventional surface ECG. It is clearly a useful tool for monitoring drug effects. Reference values for predicting intervention effect, however, are likely to be population- and context-specific and related to age, clinical types of atrial fibrillation, as well as to presence and advancement of underlying structural heart disease. Prospective studies in homogeneous patient populations are still needed to establish the clinical value of AFR.

Europace: 31 Oct 2014; 16:iv110-iv119
Platonov PG, Corino VD, Seifert M, Holmqvist F, Sörnmo L
Europace: 31 Oct 2014; 16:iv110-iv119 | PMID: 25362161
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Abstract

A comparison of genetic findings in sudden cardiac death victims and cardiac patients: the importance of phenotypic classification.

Hertz CL, Ferrero-Miliani L, Frank-Hansen R, Morling N, Bundgaard H
Sudden cardiac death (SCD) is responsible for a large proportion of non-traumatic, sudden and unexpected deaths in young individuals. Sudden cardiac death is a known manifestation of several inherited cardiac diseases. In post-mortem examinations, about two-thirds of the SCD cases show structural abnormalities at autopsy. The remaining cases stay unexplained after thorough investigations and are referred to as sudden unexplained deaths. A routine forensic investigation of the SCD victims in combination with genetic testing makes it possible to establish a likely diagnosis in some of the deaths previously characterized as unexplained. Additionally, a genetic diagnose in a SCD victim with a structural disease may not only add to the differential diagnosis, but also be of importance for pre-symptomatic family screening. In the case of SCD, the optimal establishment of the cause of death and management of the family call for standardized post-mortem procedures, genetic screening, and family screening. Studies of genetic testing in patients with primary arrhythmia disorders or cardiomyopathies and of victims of SCD presumed to be due to primary arrhythmia disorders or cardiomyopathies, were systematically identified and reviewed. The frequencies of disease-causing mutation were on average between 16 and 48% in the cardiac patient studies, compared with ∼10% in the post-mortem studies. The frequency of pathogenic mutations in heart genes in cardiac patients is up to four-fold higher than that in SCD victims in a forensic setting. Still, genetic investigation of SCD victims is important for the diagnosis and the possible investigation of relatives at risk.

Europace: 26 Oct 2014; epub ahead of print
Hertz CL, Ferrero-Miliani L, Frank-Hansen R, Morling N, Bundgaard H
Europace: 26 Oct 2014; epub ahead of print | PMID: 25345827
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Abstract

New devices in heart failure: an European Heart Rhythm Association report: Developed by the European Heart Rhythm Association; Endorsed by the Heart Failure Association.

Kuck KH, Bordachar P, Borggrefe M, Boriani G, ... Tavazzi L, Ruschitzka F
Several new devices for the treatment of heart failure (HF) patients have been introduced and are increasingly used in clinical practice or are under clinical evaluation in either observational and/or randomized clinical trials. These devices include cardiac contractility modulation, spinal cord stimulation, carotid sinus nerve stimulation, cervical vagal stimulation, intracardiac atrioventricular nodal vagal stimulation, and implantable hemodynamic monitoring devices. This task force believes that an overview on these technologies is important. Special focus is given to patients with HF New York Heart Association Classes III and IV and narrow QRS complex, who represent the largest group in HF compared with patients with wide QRS complex. An overview on potential device options in addition to optimal medical therapy will be helpful for all physicians treating HF patients.

Europace: 21 Nov 2013; epub ahead of print
Kuck KH, Bordachar P, Borggrefe M, Boriani G, ... Tavazzi L, Ruschitzka F
Europace: 21 Nov 2013; epub ahead of print | PMID: 24265466
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Clinical response with adaptive CRT algorithm compared with CRT with echocardiography-optimized atrioventricular delay: a retrospective analysis of multicentre trials.

Singh JP, Abraham WT, Chung ES, Rogers T, ... Coles JA, Martin DO
Adaptive cardiac resynchronization therapy (aCRT) is a novel algorithm for CRT pacing that provides automatic ambulatory selection between synchronized left ventricular (LV) or bi-ventricular (BiV) pacing and optimization of atrioventricular (AV) and inter-ventricular (VV) delays based on periodic measurement of intrinsic conduction. We aimed to compare the clinical response between aCRT and standard CRT in historical trials.Methods and results: The treatment arm of the aCRT trial was compared with a pooled historical control (HC) derived from the CRT arms of four clinical trials (MIRACLE, MIRACLE ICD, PROSPECT, and InSync III Marquis) with respect to the proportion of patients who had an improved clinical composite score (CCS) at the 6-month follow-up. Patients in the HC underwent echocardiography-guided AV optimization after the implant. A propensity score model was used to adjust for 22 potential baseline confounders of the effect of CRT. Patients were stratified into quintiles according to the propensity score and the adjusted absolute treatment effect was obtained by averaging estimates across these quintiles. The propensity score model included 751 patients (aCRT: 266, historical trials: 485). The adjusted absolute difference in percent improved in CCS between the aCRT and HC arms was 11.9% [95% confidence interval (CI): 2.7-19.2%] favouring aCRT. The patients in the aCRT group were significantly more likely to have an improved CCS than the patients in the HC (odds ratio = 1.65, 95% CI: 1.1-2.5).Conclusion: The aCRT algorithm may be associated with additional improvement in clinical response compared with historical CRT with echocardiographic AV optimization.

Europace: 08 Sep 2013; epub ahead of print
Singh JP, Abraham WT, Chung ES, Rogers T, ... Coles JA, Martin DO
Europace: 08 Sep 2013; epub ahead of print | PMID: 24014804
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Abstract

Current investigation and management of patients with syncope: results of the European Heart Rhythm Association survey.

Dagres N, Bongiorni MG, Dobreanu D, Madrid A, ... conducted by the Scientific Initiatives Committee, European Heart Rhythm Association
The aim of this European Heart Rhythm Association (EHRA) survey was to provide an insight into the current practice of work-up and management of patients with syncope among members of the EHRA electrophysiology research network. Responses were received from 43 centres. The majority of respondents (74%) had no specific syncope unit and only 42% used a standardized assessment protocol or algorithm. Hospitalization rates varied from 10% to 25% (56% of the centres) to >50% (21% of the centres). The leading reasons for hospitalization were features suggesting arrhythmogenic syncope (85% of respondents), injury (80%), structural heart disease (73%), significant comorbidities (54%), and older age (41%). Most widely applied tests were electrocardiogram (ECG), echocardiography, and Holter monitoring followed by carotid sinus massage and neurological evaluation. An exercise test, tilt table test, electrophysiological study, and implantation of a loop recorder were performed only if there was a specific indication. The use of a tilt table test varied widely: 44% of respondents almost always performed it when neurally mediated syncope was suspected, whereas 37% did not perform it when there was a strong evidence for neurally mediated syncope. Physical manoeuvres were the most widely (93%) applied standard treatment for this syncope form. The results of this survey suggest that there are significant differences in the management of patients with syncope across Europe, specifically with respect to hospitalization rates and indications for tilt table testing in neurally mediated syncope. The majority of centres reported using ECG, echocardiography, and Holter monitoring as their main diagnostic tools in patients with syncope, whereas a smaller proportion of centres applied specific assessment algorithms. Physical manoeuvres were almost uniformely reported as the standard treatment for neurally mediated syncope.

Europace: 26 Nov 2013; 15:1812-5
Dagres N, Bongiorni MG, Dobreanu D, Madrid A, ... conducted by the Scientific Initiatives Committee, European Heart Rhythm Association
Europace: 26 Nov 2013; 15:1812-5 | PMID: 24280765
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Abstract

Characteristics of a large sample of candidates for permanent ventricular pacing included in the Biventricular Pacing for Atrio-ventricular Block to Prevent Cardiac Desynchronization Study (BioPace).

Funck RC, Mueller HH, Lunati M, Piorkowski C, ... Blanc JJ, for the BioPace study group
The general clinical profile of European pacemaker recipients who require predominant ventricular pacing (VP) is scarcely known. We examined the demographic and clinical characteristics of the 1808 participants (out of 1833 randomized patients) of the ongoing Biventricular Pacing for Atrio-ventricular Block to Prevent Cardiac Desynchronization (BioPace) study.Methods and results: BioPace recruited patients between May 2003 and September 2007 predominantly in European medical centres. We analysed demographic data and described clinical characteristics and electrophysiological parameters prior to device implantation in 1808 enrolled patients. The mean age ± standard deviation (SD) of the 1808 patients was 73.5 ± 9.2 years, 1235 (68%) were men, 654 (36%) presented without structural heart disease, 547 (30%) had ischemic, 355 (20%) hypertensive, 146 (8%) valvular, and 102 (6%) non-ischemic dilated cardiomyopathy. Mean left ventricular ejection fraction was 55.4 ± 12.3%. The main pacing indications were (a) permanent and intermittent atrioventricular (AV) block in 973 (54%), (b) atrial fibrillation with slow ventricular rate in 313 (17%), and (c) miscellaneous bradyarrhythmias in 522 (29%) patients. Mean QRS duration was 118.5 ± 30.5 ms, left bundle branch block was present in 316 (17%), and atrial tachyarrhythmias in 426 (24%) patients.Conclusion: To the best of our knowledge, this sample is a representative source of description of the general profile of European pacemaker recipients who require predominant VP. Patients\' characteristics included advanced age, predominantly male gender, preserved left ventricular systolic function, high-grade AV block, narrow QRS complex, and atrial tachyarrhythmias, the latter being present in nearly one-fourth of the cohort.

Europace: 07 Nov 2013; epub ahead of print
Funck RC, Mueller HH, Lunati M, Piorkowski C, ... Blanc JJ, for the BioPace study group
Europace: 07 Nov 2013; epub ahead of print | PMID: 24200715
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Abstract

The presence of extensive atrial scars hinders the differential diagnosis of focal or macroreentrant atrial tachycardias in patients with complex congenital heart disease.

Akca F, Bauernfeind T, De Groot NM, Shalganov T, Schwagten B, Szili-Torok T
Atrial tachycardias (ATs) frequently develop in patients with congenital heart defects (CHDs). This study aimed to evaluate the effects of extensive atrial scar formation on the total atrial activation time (TAAT) and its relation to the tachycardia cycle length (CL) to classify AT.Methods and results: Seventy-one patients were included and divided into two groups: patients without CHD (Group I, 35 patients) and with CHD (Group II, 36 patients). All patients underwent CARTO electroanatomical activation mapping. Two subgroups were created: centrifugal (CAT) or macroreentrant AT (MRAT). Total atrial activation time, CL, and mean bipolar signal amplitude (BiSA) were analysed. In Group I, 18 patients (51.4%) had CAT and 17 (48.6%) MRAT. The mean BiSA for Group I was 1.30 ± 0.32 mV. Total atrial activation time/CL ratios were different between CAT and MRAT (28.4 ± 16.9 vs. 66.6 ± 14.3%, P < 0.001). In Group II, 18 patients (50%) had CAT and 18 patients (50%) MRAT. The mean BiSA was 0.94 ± 0.50 mV and was not different for CAT and MRAT subgroups (1.04 ± 0.64 vs. 0.85 ± 0.29, P = 0.243). Total atrial activation time/CL ratios were comparable between CAT and MRAT patients (69.0 ± 40.4 vs. 83.6 ± 8.3%, P = 0.243). A significant lower BiSA was found for CAT with TAAT/CL ratios above 40% (0.62 ± 0.11 vs. 1.90 ± 0.18 mV, P < 0.001). A strong negative correlation was identified between the BiSA and the TAAT/CL ratio in patients with CAT in Group II (-0.742; P < 0.001).Conclusion: Low mean BiSA values in CHD patients are associated with altered impulse propagation, making TAAT- and CL-based diagnostic tools inaccurate. Further diagnostic tests are needed to determine the correct mechanism of ATs.

Europace: 26 Nov 2013; epub ahead of print
Akca F, Bauernfeind T, De Groot NM, Shalganov T, Schwagten B, Szili-Torok T
Europace: 26 Nov 2013; epub ahead of print | PMID: 24280196
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Abstract

Evidence for cardiac safety and antiarrhythmic potential of chloroquine in systemic lupus erythematosus.

Alkmim Teixeira R, Borba EF, Pedrosa A, Nishioka S, ... Bonfá E, Martinelli Filho M
To perform a comprehensive evaluation of heart rhythm disorders and the influence of disease/therapy factors in a large systemic lupus erythematosus (SLE) cohort.Methods and results: Three hundred and seventeen consecutive patients of an ongoing electronic database protocol were evaluated by resting electrocardiogram and 142 were randomly selected for 24 h Holter monitoring for arrhythmia and conduction disturbances. The mean age was 40.2 ± 12.1 years and disease duration was11.4 ± 8.1 years. Chloroquine (CQ) therapy was identified in 69.7% with a mean use of 8.5 ± 6.7 years. Electrocardiogram abnormalities were detected in 66 patients (20.8%): prolonged QTc/QTd (14.2%); bundle-branch block (2.5%); and atrioventricular block (AVB) (1.6%). Age was associated with AVB (P = 0.029) and prolonged QTc/QTd (P = 0.039) whereas anti-Ro/SS-A and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores were not (P > 0.05). Chloroquine was negatively associated with AVB (P = 0.01) as was its longer use (6.1 ± 6.9 vs. 1.0 ± 2.5 years, P = 0.018). Time of CQ use was related with the absence of AVB [odds ratio (OR) = 0.103; 95% confidence interval (CI) = 0.011-0.934, P = 0.043] in multiple logistic regression. Holter monitoring revealed abnormalities in 121 patients (85.2%): supraventricular ectopies (63.4%) and tachyarrhythmia (18.3%); ventricular ectopies (45.8%). Atrial tachycardia/fibrillation (AT/AF) were associated with shorter CQ duration (7.05 ± 7.99 vs. 3.63 ± 5.02 years, P = 0.043) with a trend to less CQ use (P = 0.054), and older age (P < 0.001). Predictors of AT/AF in multiple logistic regression were age (OR = 1.115; 95% CI = 1.059-1.174, P < 0.001) and anti-Ro/SS-A (OR = 0.172; 95% CI = 0.047-0.629, P = 0.008).Conclusions: Chloroquine seems to play a protective role in the unexpected high rate of cardiac arrhythmias and conduction disturbances observed in SLE. Further studies are necessary to determine if this antiarrhythmic effect is due to the disease control or a direct effect of the drug.

Europace: 19 Sep 2013; epub ahead of print
Alkmim Teixeira R, Borba EF, Pedrosa A, Nishioka S, ... Bonfá E, Martinelli Filho M
Europace: 19 Sep 2013; epub ahead of print | PMID: 24050965
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Pharmacological cardioversion of atrial fibrillation with vernakalant: evidence in support of the ESC Guidelines.

Savelieva I, Graydon R, Camm AJ
Pharmacological rhythm control (often including electrical or pharmacological cardioversion) is an integral part of therapy for atrial fibrillation (AF) worldwide. Antiarrhythmic drug strategies would be preferred in many patients provided effective and safe antiarrhythmic agents are available. Also, pharmacological cardioversion could be the preferred option if the limitations of currently available drugs, such as restriction to patients without structural heart disease (flecainide and propafenone), risk of torsade de pointes (ibutilide), and slow onset of action (amiodarone), were overcome. The intravenous formulation of vernakalant (Brinavess, Cardiome) has been approved for pharmacological cardioversion of recent-onset AF (≤7 days) and early (≤3 days) post-operative AF in the European Union, Iceland, and Norway. Vernakalant has a high affinity to ion channels specifically involved in repolarization of atrial tissue and has minimal effects in the ventricles and thus, is thought to have a low proarrhythmic potential. Vernakalant is administered as a 10 min infusion of 3 mg/kg, and if AF persists after 15 min, an additional dose of 2 mg/kg can be given. The efficacy and safety of the drug has been extensively investigated in randomized controlled trials against placebo and an active comparator (amiodarone). The placebo-extracted efficacy of vernakalant is ∼47%. A significant advantage is a rapid effect, with the median to conversion ranging between 8 and 14 min, with the majority of patients (75-82%) converting after the first dose. Vernakalant retained its efficacy in subgroups of patients with associated cardiovascular disease such as hypertension and ischaemic heart disease, but its benefit may be lower and risk of adverse effects is higher in patients with heart failure. In the post-market reports, cardioversion rates with vernakalant are 65-70%. This review focuses on the role of vernakalant in pharmacological cardioversion for AF.

Europace: 09 Oct 2013; epub ahead of print
Savelieva I, Graydon R, Camm AJ
Europace: 09 Oct 2013; epub ahead of print | PMID: 24108230
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Abstract

Risk prediction of ventricular arrhythmias and myocardial function in Lamin A/C mutation positive subjects.

Hasselberg NE, Edvardsen T, Petri H, Berge KE, ... Bundgaard H, Haugaa KH
Mutations in the Lamin A/C gene may cause atrioventricular block, supraventricular arrhythmias, ventricular arrhythmias (VA), and dilated cardiomyopathy. We aimed to explore the predictors and the mechanisms of VA in Lamin A/C mutation-positive subjects.Methods and results: We included 41 Lamin A/C mutation-positive subjects. PR-interval and occurrence of VA were recorded. Left ventricular (LV) myocardial function was assessed as ejection fraction and speckle tracking longitudinal strain by echocardiography. Magnetic resonance imaging was performed to assess fibrosis in a selection of subjects. Ventricular arrhythmias were documented in 21 patients (51%). Prolonged PR-interval was the best predictor of VA (P < 0.001). Myocardial function by strain was reduced in the interventricular septum compared with the rest of the LV segments (-16.7% vs. -18.7%, P = 0.001) and correlated to PR-interval (R = 0.41, P = 0.03). Myocardial fibrosis was found exclusively in the interventricular septum and only in patients with VA (P = 0.007). PR-interval was longer in patients with septal fibrosis compared with those without (320 ± 66 vs. 177 ± 40 ms, P < 0.001).Conclusion: Prolonged PR-interval was the best predictor of VA in Lamin A/C mutation-positive subjects. Electrical, mechanical, and structural cardiac properties were related in these subjects. Myocardial function was most reduced in the interventricular septum and correlated to prolonged PR-interval. Myocardial septal fibrosis was associated with prolonged PR-interval and VA. Localized fibrosis in the interventricular septum may be the mechanism behind reduced septal function, atrioventricular block and VA in Lamin A/C mutation-positive subjects.

Europace: 22 Sep 2013; epub ahead of print
Hasselberg NE, Edvardsen T, Petri H, Berge KE, ... Bundgaard H, Haugaa KH
Europace: 22 Sep 2013; epub ahead of print | PMID: 24058181
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36Experiences from a non-medical, non-cardiac catheter laboratory based implantale loop recorder service.

Mercer C, Roebuck A, Denman J, Andrews R
Implantable Loop Recorders (ILR\'s)are small subcutaneous single lead ECG monitoring devices that are placed in a left pectoral pocket under local analgesia. Traditionally, devices have been implanted by medical staffs (consultants/registrars) in the Cardiac Catheter Laboratory (Cath Lab). Each implant can take between 30-45 minutes depending on operator skill and patient anatomy. This paper details the experiences of 2 nurses and 1 physiologist who have developed a non-medical, non-cardiac catheter laboratory (Cath Lab) implantation service. The development of a non-medical, non-Cath Lab service has had several major patient and organisational benefits that include shorter waiting times, less cancellations, more patient centred clinical environment (many patients find the Cath Lab "scary"/"intimidating" and increased flexibility to implant \'urgent\' Transient Loss of Consciousness (TLOC) devices. The latter has reduced length of stay within our Emergency Assessment Unit. Moreover, this service means that the department has been able to undertake more procedures in the Cath Lab. Based on 2013-14 data 32 x4 hour Cath Lab sessions were made available for alternative use - potentially an additional 64 angioplasties. When the team commenced the service all patients were cannulated and received Intravenous (IV) antibiotics prophylactically. A literature review did not support this practice and thus a prospective audit (n=100) was undertaken of device implantation without antimicrobial prophylactic cover. There was no statistical difference noted with approximately 1% of implants with or without antimicrobial cover suffering from an erosion or pocket infection (the audit was undertaken on an NNT basis and included patients who were thought to have manipulated their device/wound). This compares favourably with published data suggesting a 1-2% risk of erosion/infection. Devices are also implanted on anti-coagulated patients (NOAC/ warfarin) provided their INR is <3. Physiologists are non-mandatory registered healthcare professionals hence it is illegal for them to use a Patient Group Directions (PGD\'s) to administer local analgesia. As such we had to amend the Trusts \'Medicines Management Policy\' to allow \'named patient\' administration. The service has recently began implanting the Metronic LINQ (an injectable device opposed to a surgically implanted device) that has reduced the procedural time from 30-minutes to 10-minutes. Other advantages are a smaller wounds, less bruising, and less body image concerns in our female clients. There is also a reduced requirement for surgical skills training with his device thus making the transition out of the Cath Lab easier. To conclude; we believe that non-medical ILR implantation outside of the Cath Lab is clinically safe, cost efficacious and delivers significant pathway improvements for the patient.

Europace: 08 Oct 2014; 16:iii15
Mercer C, Roebuck A, Denman J, Andrews R
Europace: 08 Oct 2014; 16:iii15 | PMID: 25298443
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Opportunities and challenges of current electrophysiology research: a plea to establish \'translational electrophysiology\' curricula.

Lau DH, Volders PG, Kohl P, Prinzen FW, ... Oto A, Schotten U
Cardiac electrophysiology has evolved into an important subspecialty in cardiovascular medicine. This is in part due to the significant advances made in our understanding and treatment of heart rhythm disorders following more than a century of scientific discoveries and research. More recently, the rapid development of technology in cellular electrophysiology, molecular biology, genetics, computer modelling, and imaging have led to the exponential growth of knowledge in basic cardiac electrophysiology. The paradigm of evidence-based medicine has led to a more comprehensive decision-making process and most likely to improved outcomes in many patients. However, implementing relevant basic research knowledge in a system of evidence-based medicine appears to be challenging. Furthermore, the current economic climate and the restricted nature of research funding call for improved efficiency of translation from basic discoveries to healthcare delivery. Here, we aim to (i) appraise the broad challenges of translational research in cardiac electrophysiology, (ii) highlight the need for improved strategies in the training of translational electrophysiologists, and (iii) discuss steps towards building a favourable translational research environment and culture.

Europace: 17 Feb 2015; epub ahead of print
Lau DH, Volders PG, Kohl P, Prinzen FW, ... Oto A, Schotten U
Europace: 17 Feb 2015; epub ahead of print | PMID: 25691491
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40Dot mapping: a novel technique for dual electrophysiological dataset representation facilitates recognition of complex intra-atrial re-entrant tachycardia substrate in repaired adult congenital heart disease.

Chubb H, Linton N, Rhode K, Gill J, ... O\'Neill M, Williams SE
Adult congenital heart disease (ACHD) patients have a high lifetime prevalence of reentrant atrial arrhythmia, secondary to both the anatomic lesion and surgical repair. Catheter ablation is an effective treatment for atrial tachycardia (AT), however current electroanatomical mapping (EAM) systems permit the display of only a single data modality per shell at a given time. Localised voltages can reveal prior structural information critically related to arrhythmia mechanisms. A bipolar voltage threshold of <0.05mV has traditionally been accepted for the annotation of scar (based on the noise threshold of the Carto system), with voltage <0.5mV taken to represent abnormal atrial tissue. We sought to assess the feasibility of dual representation of activation time (LAT) and voltage on the atrial shell of patients with repaired congenital heart disease.

Europace: 08 Oct 2014; 16:iii16
Chubb H, Linton N, Rhode K, Gill J, ... O'Neill M, Williams SE
Europace: 08 Oct 2014; 16:iii16 | PMID: 25298446
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The importance of specialist cardiac histopathological examination in the investigation of young sudden cardiac deaths.

de Noronha SV, Behr ER, Papadakis M, Ohta-Ogo K, ... Sharma S, Sheppard MN
Post-mortem examination of the heart in young sudden cardiac death (SCD) is vital as the underlying aetiology is often an inherited cardiac disease with implications for surviving relatives. Our aim is to demonstrate the improvement in diagnostic quality offered by a specialist cardiac pathology service established to investigate SCD with fast-track reporting on hearts sent by pathologists in cases of SCD.Methods and results: A tertiary centre prospective observational study was conducted. Detailed histopathological examination was performed in a tertiary centre specialized in the investigation of cardiac pathology in SCD. Hearts from 720 consecutive cases of SCD referred by coroners and pathologists from 2007 to 2009 were included. A comparison was drawn with diagnoses from referring pathologists. Most SCDs occurred in males (66%), with the median age being 32 years. The majority (57%) of deaths occurred at home. The main diagnoses were a morphologically normal heart (n = 321; 45%), cardiomyopathy (n = 207, 29%), and coronary artery pathology (n = 71; 10%). In 158 out of a sample of 200 consecutive cases, a cardiac examination was also performed by the referring pathologist with a disparity in diagnosis in 41% of the cases (κ = 0.48). Referring pathologists were more inclined to diagnose cardiomyopathy than normality with only 50 out of 80 (63%) normal hearts being described correctly.Conclusion: Expert cardiac pathology improves the accuracy of coronial post-mortem diagnoses in young SCD. This is important as the majority of cases may be due to inherited cardiac diseases and the autopsy guides the appropriate cardiological evaluation of blood relatives for their risk of sudden death.

Europace: 22 Oct 2013; epub ahead of print
de Noronha SV, Behr ER, Papadakis M, Ohta-Ogo K, ... Sharma S, Sheppard MN
Europace: 22 Oct 2013; epub ahead of print | PMID: 24148315
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Estimation of the origin of ventricular outflow tract arrhythmia using synthesized right-sided chest leads.

Nakano M, Ueda M, Ishimura M, Kajiyama T, ... Hiranuma Y, Kobayashi Y
For successful ablation of ventricular outflow tract arrhythmia, estimation of its origin prior to the procedure can be useful. Morphology and lead placement in the right thoracic area may be useful for this purpose. Electrocardiography using synthesized right-sided chest leads (Syn-V3R, Syn-V4R, and Syn-V5R) is performed using standard leads without any additional leads. This study evaluated the usefulness of synthesized right-sided chest leads in estimating the origin of ventricular outflow tract arrhythmia.Methods and results: This retrospective study included 63 patients in whom successful ablation of ventricular outflow tract arrhythmia was performed. Numbers of arrhythmias originating from the left ventricle, the septum of the right ventricle, and the free wall of the right ventricle were 11, 40, and 13, respectively. In one patient, two different left ventricular outflow tract origins were found. Electrocardiographic recordings from right-sided chest leads were divided into three types as follows: those in which an R > S concordance, a transitional zone, or an R < S concordance were detected. In all left arrhythmia cases, R > S concordance was observed. A transitional zone was evident in 34 of 40 cases of right ventricular outflow tract arrhythmia originating in the ventricular septum, and an R < S concordance was observed in 6 of the 40 cases. However, an R < S concordance was found in all cases of right ventricular outflow tract arrhythmia originating in the free wall.Conclusion: Synthesized right-sided chest lead electrocardiography may be useful for estimating the origin of ventricular outflow tract arrhythmia.

Europace: 27 Nov 2013; epub ahead of print
Nakano M, Ueda M, Ishimura M, Kajiyama T, ... Hiranuma Y, Kobayashi Y
Europace: 27 Nov 2013; epub ahead of print | PMID: 24284987
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Management of antithrombotic therapy in patients undergoing electrophysiological device surgery.

Zacà V, Marcucci R, Parodi G, Limbruno U, ... Bongiorni MG, Casolo G
The aim of this review is to formulate practical recommendations for the management of antithrombotic therapy in patients undergoing cardiac implantable electronic device (CIED) surgery by providing indications for a systematic approach to the problem integrating general technical considerations with patient-specific elements based on a careful evaluation of the balance between haemorrhagic and thromboembolic risk. Hundreds of thousands patients undergo implantation or replacement of CIEDs annually in Europe, and up to 50% of these subjects receive antiplatelet agents or oral anticoagulants. The rate of CIED-related complications, mainly infective, has also significantly increased so that transvenous lead extraction procedures are, consequently, often required. Cardiac implantable electronic device surgery is peculiar and portends specific intrinsic risks of developing potentially fatal haemorrhagic complications; on the other hand, the periprocedural suspension of antithrombotic therapy in patients with high thromboembolic risk cardiac conditions may have catastrophic consequences. Accordingly, the management of the candidate to CIED surgery receiving concomitant antithrombotic therapy is a topic of great clinical relevance yet controversial and only partially, if at all, adequately addressed in evidence-based current guidelines. In spite of the fact that in many procedures it seems reasonably safe to proceed with aspirin only or without interruption of anticoagulants, restricting to selected cases the use of bridging therapy with parenteral heparins, there are lots of variables that may make the therapeutic choices challenging. The decision-making process applied in this document relies on the development of a stratification of the procedural haemorrhagic risk and of the risk deriving from the suspension of antiplatelet or anticoagulant therapy combined to generate different clinical scenarios with specific indications for optimal management of periprocedural antithrombotic therapy.

Europace: 24 Feb 2015; epub ahead of print
Zacà V, Marcucci R, Parodi G, Limbruno U, ... Bongiorni MG, Casolo G
Europace: 24 Feb 2015; epub ahead of print | PMID: 25712980
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Abstract

Altered fibrin clot properties and fibrinolysis in patients with atrial fibrillation: practical implications.

Undas A

Compelling evidence indicates that a hypercoagulable state occurs in patients with atrial fibrillation (AF) including those in sinus rhythm following paroxysmal and persistent AF. Activation of blood coagulation in AF reflects heightened thrombin generation with the subsequent increased formation of fibrin as evidenced by elevated soluble fibrin monomers and D-dimer. Formation of denser fibrin meshworks, relatively resistant to plasmin-mediated lysis has been demonstrated in patients with AF. The presence of stroke risk factors in AF, such as diabetes, heart failure, hypertension, previous myocardial infarction, or stroke, advanced age have been shown to be linked to the prothrombotic clot characteristics, including reduced clot permeability and lysability. Importantly, biomarkers, including cardiac troponins and N-terminal pro-brain natriuretic peptide, are associated with thrombin generation and fibrin-related markers in AF patients. Recently, increased fibrin clot density (low clot permeability measured in plasma-based assays) and impaired fibrinolysis measured off anticoagulation have been demonstrated to predict ischaemic cerebrovascular events in patients with AF receiving vitamin K antagonists and those on rivaroxaban. The current review summarizes evidence for a role of altered fibrin clot properties and hypofibrinolysis in AF and their prognostic value in terms of adverse events.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Europace: 17 Oct 2019; epub ahead of print
Undas A
Europace: 17 Oct 2019; epub ahead of print | PMID: 31625555
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Abstract

Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on atrial fibrillation: primary results of the PREvention oF thromboemolic events--European Registry in Atrial Fibrillation (PREFER in AF).

Kirchhof P, Ammentorp B, Darius H, De Caterina R, ... Schmitt J, Zamorano JL
We sought to describe the management of patients with atrial fibrillation (AF) in Europe after the release of the 2010 AF Guidelines of the European Society of Cardiology.Methods and results: The PREFER in AF registry enrolled consecutive patients with AF from January 2012 to January 2013 in 461 centres in seven European countries. Seven thousand two hundred and forty-three evaluable patients were enrolled, aged 71.5 ± 11 years, 60.1% male, CHA2DS2VASc score 3.4 ± 1.8 (mean ± standard deviation). Thirty per cent patients had paroxysmal, 24.0% had persistent, 7.2% had long-standing persistent, and 38.8% had permanent AF. Oral anticoagulation was used in the majority of patients: 4799 patients (66.3%) received a vitamin K antagonist (VKA) as mono-therapy, 720 patients a combination of VKA and antiplatelet agents (9.9%), 442 patients (6.1%) a new oral anticoagulant drugs (NOAC). Antiplatelet agents alone were given to 808 patients (11.2%), no antithrombotic therapy to 474 patients (6.5%). Of 7034 evaluable patients, 5530 (78.6%) patients were adequately rate controlled (mean heart rate 60-100 bpm). Half of the patients (50.7%) received rhythm control therapy by electrical cardioversion (18.1%), pharmacological cardioversion (19.5%), antiarrhythmic drugs (amiodarone 24.1%, flecainide or propafenone 13.5%, sotalol 5.5%, dronedarone 4.0%), and catheter ablation (5.0%).Conclusion: The management of AF patients in 2012 has adapted to recent evidence and guideline recommendations. Oral anticoagulant therapy with VKA (majority) or NOACs is given to over 80% of eligible patients, including those at risk for bleeding. Rate is often adequately controlled, and rhythm control therapy is widely used.

Europace: 01 Oct 2013; epub ahead of print
Kirchhof P, Ammentorp B, Darius H, De Caterina R, ... Schmitt J, Zamorano JL
Europace: 01 Oct 2013; epub ahead of print | PMID: 24084680
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Abstract

Left ventricular lead stabilization to retain cardiac resynchronization therapy at long term: when is it advisable?

Biffi M, Bertini M, Ziacchi M, Diemberger I, Martignani C, Boriani G
Left ventricular (LV) lead dislodgement occurs in about 10.6% of patients in the first 12 months after cardiac resynchronization therapy defibrillator implantation, and causes lack of clinical improvement, repeated surgery, and predisposes to infective complications and death. To understand the factors predictive of lead dislodgement, and to investigate whether bipolar LV lead stabilization can reduce the dislodgement rate and improve the clinical outcome.Methods and results: Predisposing coronary vein anatomy was identified on a retrospective series of 218 patients implanted before August 2009. Lead stabilization guided by vein anatomy was prospectively tested on consecutive patients from October 2009 to December 2010. Among 84 patients, lead stabilization based on vein anatomy was recommended in 19 patients, of which 16 agreed and 3 refused. Two of these latter had lead dislodgement within 1 month, whereas none of the former had adverse events during 23.8 ± 3.1 months follow-up. Only 1 of 58 patients deemed at low risk had lead dislodgement. Seven patients required lead stabilization for severe phrenic stimulation issues that dictated lead placement at specific sites. Patients with stabilized LV leads were more likely to be cardiac resynchronization therapy (CRT) responders than the others: 19 of 26 (73%) vs. 34 of 58 (59%, P= NS), and had a significantly higher proportion of super-responders: 12 of 26 (46%) vs. 12 of 58 (21%, P< 0.005).Conclusion: Coronary vein anatomy may assist decision making about the need for LV lead stabilization, and the choice of tools during the implanting procedure to ensure effective CRT delivery at long term.

Europace: 26 Sep 2013; epub ahead of print
Biffi M, Bertini M, Ziacchi M, Diemberger I, Martignani C, Boriani G
Europace: 26 Sep 2013; epub ahead of print | PMID: 24072448
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Abstract

Cavo-tricuspid isthmus radiofrequency ablation using a novel remote navigation catheter system in patients with typical atrial flutter.

López-Gil M, Salgado R, Merino JL, Datino T, ... Fontenla A, Arribas F
A new remote catheter system (AMIGO™ Remote Catheter System) compatible with conventional ablation catheters is now commercially available but no data about its performance in clinical use during ablation have been reported. This study evaluates the feasibility, efficacy, and safety of cavo-tricuspid isthmus (CTI) ablation with this system in patients with typical atrial flutter (AFl).Methods and results: Sixty patients with typical AFl underwent CTI ablation using the new remote catheter navigation system with 8 mm tip or irrigated catheters in three centres following each centre\'s routine practice. The endpoint was stable bidirectional CTI block. CTI ablation was successful in 98% of patients. Ablation was completed manually in one patient. The overall procedure, fluoroscopy, and radiofrequency times (median ± standard deviation, range) were 123 ± 42 (50-250), 24 ± 13 (3-82), and 10 ± 8 (1.17-43.3) min, respectively. Three patients had vascular complications not requiring surgical intervention. There were no complications related to the remote catheter manipulation system.Conclusion: Cavo-tricuspid isthmus ablation for typical AFl can be safely and effectively performed with the AMIGO™. The learning curve seems to be short even for physicians with limited ablation experience.

Europace: 22 Sep 2013; epub ahead of print
López-Gil M, Salgado R, Merino JL, Datino T, ... Fontenla A, Arribas F
Europace: 22 Sep 2013; epub ahead of print | PMID: 24058180
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Abstract

Common SCN10A variants modulate PR interval and heart rate response during atrial fibrillation.

Delaney JT, Muhammad R, Shi Y, Schildcrout JS, ... Roden DM, Darbar D
SCN10A encodes the sodium channel Nav1.8 implicated by genome-wide association studies as a modulator of atrioventricular conduction (PR interval). In a cohort of patients with atrial fibrillation (AF), we examined whether there was an association between common variants in SCN10A and both the PR interval during normal sinus rhythm and the heart rate response during AF.Methods and results: Patients prospectively enrolled in the Vanderbilt AF registry with electrocardiograms in normal sinus rhythm and/or AF within 1 year of enrollment were genotyped for two common SCN10A variants rs6795970 and rs12632942. Both variants were associated with the PR interval duration in a gene-dose effect on unadjusted analysis; after adjustment for the covariates age, gender, body mass index, hypertension, congestive heart failure, and medication usage, the association remained for rs6795970 only (P = 0.012, partial R(2) = 0.0139). On unadjusted analysis, heart rate response during AF was associated with rs6795970 (P = 0.035, partial R(2) = 0.015), but not with rs12632942 (P = 0.89), and neither association was significant after adjustment for covariates.Conclusion: The common variant rs6795970 in SCN10A is associated with the PR interval duration among healthy patients and those with AF. In addition, this single nucleotide polymorphism trended towards an association with heart rate response during AF indicating the importance of this common SCN10A polymorphism as a marker of atrioventricular conduction.

Europace: 26 Sep 2013; epub ahead of print
Delaney JT, Muhammad R, Shi Y, Schildcrout JS, ... Roden DM, Darbar D
Europace: 26 Sep 2013; epub ahead of print | PMID: 24072447
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Abstract

Heart rate turbulence predicts ICD-resistant mortality in ischaemic heart disease.

Marynissen T, Floré V, Heidbuchel H, Nuyens D, Ector J, Willems R
In high-risk patients, implantable cardioverter-defibrillators (ICDs) can convert the mode of death from arrhythmic to pump failure death. Therefore, we introduced the concept of \'ICD-resistant mortality\' (IRM), defined as death (a) without previous appropriate ICD intervention (AI), (b) within 1 month after the first AI, or (c) within 1 year after the initial ICD implantation. Implantable cardioverter-defibrillator implantation in patients with a high risk of IRM should be avoided.Methods and results: Implantable cardioverter-defibrillator patients with ischaemic heart disease were included if a digitized 24 h Holter was available pre-implantation. Demographic, electrocardiographic, echocardiographic, and 24 h Holter risk factors were collected at device implantation. The primary endpoint was IRM. Cox regression analyses were used to test the association between predictors and outcome. We included 130 patients, with a mean left ventricular ejection fraction (LVEF) of 33.6 ± 10.3%. During a follow-up of 52 ± 31 months, 33 patients died. There were 21 cases of IRM. Heart rate turbulence (HRT) was the only Holter parameter associated with IRM and total mortality. A higher New York Heart Association (NYHA) class and a lower body mass index were the strongest predictors of IRM. Left ventricular ejection fraction predicted IRM on univariate analysis, and was the strongest predictor of total mortality. The only parameter that predicted AI was non-sustained ventricular tachycardia.Conclusion: Implantable cardioverter-defibrillator implantation based on NYHA class and LVEF leads to selection of patients with a higher risk of IRM and death. Heart rate turbulence may have added value for the identification of poor candidates for ICD therapy. Available Holter parameters seem limited in their ability to predict AI.

Europace: 06 Nov 2013; epub ahead of print
Marynissen T, Floré V, Heidbuchel H, Nuyens D, Ector J, Willems R
Europace: 06 Nov 2013; epub ahead of print | PMID: 24196450
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Abstract

Effect of dronedarone on clinical end points in patients with atrial fibrillation and coronary heart disease: insights from the ATHENA trial.

Pisters R, Hohnloser SH, Connolly SJ, Torp-Pedersen C, ... Crijns HJ, for the ATHENA Investigators
This study aimed to assess safety and cardiovascular outcomes of dronedarone in patients with paroxysmal or persistent atrial fibrillation (AF) with coronary heart disease (CHD). Coronary heart disease is prevalent among AF patients and limits antiarrhythmic drug use because of their potentially life-threatening ventricular proarrhythmic effects.Methods and results: This post hoc analysis evaluated 1405 patients with paroxysmal or persistent AF and CHD from the ATHENA trial. Follow-up lasted 2.5 years, during which patients received either dronedarone (400 mg twice daily) or a double-blind matching placebo. Primary outcome was time to first cardiovascular hospitalization or death due to any cause. Secondary end points included first hospitalization due to cardiovascular events. The primary outcome occurred in 350 of 737 (47%) placebo patients vs. 252 of 668 (38%) dronedarone patients [hazard ratio (HR) = 0.73; 95% confidence interval (CI) = 0.62-0.86; P = 0.0002] without a significant increase in number of adverse events. In addition, 42 of 668 patients receiving dronedarone suffered from a first acute coronary syndrome compared with 67 of 737 patients from the placebo group (HR = 0.67; 95% CI = 0.46-0.99; P = 0.04).Conclusion: In this post hoc analysis, dronedarone on top of standard care in AF patients with CHD reduced cardiovascular hospitalization or death similar to that in the overall ATHENA population, and reduced a first acute coronary syndrome. Importantly, the safety profile in this subpopulation was also similar to that of the overall ATHENA population, with no excess in proarrhythmias. The mechanism of the cardiovascular protective effects is unclear and warrants further investigation.

Europace: 26 Sep 2013; epub ahead of print
Pisters R, Hohnloser SH, Connolly SJ, Torp-Pedersen C, ... Crijns HJ, for the ATHENA Investigators
Europace: 26 Sep 2013; epub ahead of print | PMID: 24072451
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Abstract

Pulmonary vein isolation in patients with Brugada syndrome and atrial fibrillation: a 2-year follow-up.

Conte G, Chierchia GB, Wauters K, De Asmundis C, ... Saitoh Y, Brugada P
Pharmacological treatment of atrial fibrillation (AF) in the setting of Brugada syndrome (BS) might be challenging as many antiarrhythmic drugs (AADs) with sodium channel blocking properties might expose the patients to the development of ventricular arrhythmias. Moreover, patients with BS and implantable cardioverter-defibrillator (ICD) might experience inappropriate shocks because of AF with rapid ventricular response. The role of pulmonary vein isolation (PVI) in patients with BS and recurrent episodes of AF has not been established yet. In this study, we analysed the outcome of PVI using radiofrequency energy or cryoballoon (CB) ablation at 2 years follow-up.Methods and results: Consecutive patients with BS having undergone PVI for drug-resistant paroxysmal AF were eligible for this study. Nine patients (three males; mean age: 52 ± 26 years) were included. Six patients (67%) had an ICD implanted of whom three had inappropriate shocks because of rapid AF. At a mean 22.1 ± 6.4 months follow-up, six patients (67%) were free of AF without AADs. None of the three patients who had experienced inappropriate ICD interventions for AF had further ICD shocks after ablation.Conclusion: In our study PVI can be an effective and safe procedure to treat patients with BS and recurrent episodes of paroxysmal AF.

Europace: 09 Oct 2013; epub ahead of print
Conte G, Chierchia GB, Wauters K, De Asmundis C, ... Saitoh Y, Brugada P
Europace: 09 Oct 2013; epub ahead of print | PMID: 24108229
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Abstract

Characterization of the impact of catheter-tissue contact force in lesion formation during cavo-tricuspid isthmus ablation in an experimental swine model.

Matía Francés R, Hernández Madrid A, Delgado A, Carrizo L, ... Moro Serrano C, Zamorano Gómez JL
Catheter-tissue contact is critical for effective lesion creation. The objective of this study was to determine in an experimental swine model the pathological effects of cavo-tricuspid isthmus ablation using two systems that provide reliable measures of the pressure at the catheter tip during radiofrequency ablation procedures.Methods and results: We performed the procedure in eight pigs in our experimental electrophysiology laboratory after right femoral vein dissection and insertion of a 12 Fr. introducer during general anaesthesia and endotracheal intubation. The target contact force during the applications was <10 grs. (axial or lateral), 10-20, 20-30, and >30 grs. in two pigs each. The power was set at 40 W and maximum target temperature at 45°C. We performed a radiofrequency line dragging from the tricuspid valve to the inferior vena cava in the eight pigs. Euthanasia of the animals was carried out a week after the procedure and a pathological examination of the lesions was performed. In the endocardial macroscopic analysis the extent of lesions, presence of thrombus, transmurality, and endothelial rupture was assessed. External surface was examined searching for transmural lesions. The mean contact force applied was 18.7 ± 8.4 grs. and the mean depth of the lesions was 3.6 ± 2 mm. Lesions were never transmural with average forces <10 grs., and the mean depth was very low (0.75 mm). To achieve transmural lesions contact forces of at least 20 grs. were required. We found a positive correlation (r = 0.85, P < 0.05) between the average force during the applications and depth of the lesions.Conclusion: When ablating the cavo-tricuspid isthmus in a swine model, contact forces of at least 20 grs. are required to achieve transmural lesions. Catheter-tissue contact is critical for effective lesion creation. This information is important for improving ablation efficacy.

Europace: 13 Nov 2013; epub ahead of print
Matía Francés R, Hernández Madrid A, Delgado A, Carrizo L, ... Moro Serrano C, Zamorano Gómez JL
Europace: 13 Nov 2013; epub ahead of print | PMID: 24225068
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Abstract

Coronary artery reperfusion for ST elevation myocardial infarction is associated with shorter cycle length ventricular tachycardia and fewer spontaneous arrhythmias.

Nalliah CJ, Zaman S, Narayan A, Sullivan J, Kovoor P
Ventricular tachycardia (VT) induction at electrophysiological (EP) study early after ST elevation myocardial infarction (STEMI) has been a predictor of spontaneous ventricular arrhythmia. Reperfusion therapy for STEMI may have resulted in altered VT character. We attempted to determine differences in VT cycle length (CL) and VT recurrence rates, in patients who received early and late reperfusion treatment for STEMI.Methods and results: Of 180 consecutive patients with left ventricular ejection fraction < 40%, 77 patients had positive EP studies. Forty-nine patients receiving early reperfusion treatment (group 1, n = 49) were compared with 28 patients who received late reperfusion (group 2; n = 28). Seventy-five patients had defibrillators implanted for primary prevention of sudden death. Patients were followed for up to 6 years to assess long-term rates of spontaneous ventricular tachyarrhythmia. Patients who received early reperfusion demonstrated shorter CL inducible VT (231 ± 43 ms vs. 252 ± 56 ms; P = 0.016). They also had fewer spontaneous arrhythmias (adjusted hazard ratio of 2.94, 95% confidence interval: 1.07-8.13; P = 0.03) with shorter CL spontaneous VT (266 ± 54 ms vs. 320 ± 80 ms; P = 0.02) at 53 ± 33 months. Ventricular tachycardia CL was the only independent predictor of spontaneous arrhythmia or sudden cardiac death (1.22, 1.07-1.47; P = 0.016).Conclusions: Patients receiving early reperfusion for STEMI had faster inducible and spontaneous VT and fewer spontaneous recurrences. This may be due to changes in the myocardial substrate as a result of early coronary artery reperfusion.

Europace: 24 Oct 2013; epub ahead of print
Nalliah CJ, Zaman S, Narayan A, Sullivan J, Kovoor P
Europace: 24 Oct 2013; epub ahead of print | PMID: 24158256
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Abstract

Long-term follow-up of asymptomatic Brugada patients with inducible ventricular fibrillation under hydroquinidine.

Bouzeman A, Traulle S, Messali A, Extramiana F, ... Hermida JS, Leenhardt A
To evaluate the long-term efficacy and safety of an electrophysiologically guided therapy, based on a strategy of treatment using hydroquinidine (HQ) among asymptomatic Brugada patients with inducible ventricular fibrillation (VF).Methods and results: In two French reference centres, consecutive asymptomatic type 1 Brugada patients with inducible VF were treated with HQ (600 mg/day, targeting a therapeutic range between 3 and 6 µmol/L) and enroled in a specific follow-up (mean 6.6 ± 3 years), including a second programmed ventricular stimulation (PVS) under HQ. An implantable cardioverter defibrillator (ICD) was eventually implanted in patients inducible under HQ, or during follow-up in case of HQ intolerance, as well as occurrence of arrhythmic events. From a total of 397 Brugada patients, 44 were enroled (47 ± 10 years, 95% male). Of these, 34 (77%) were no more inducible (Group PVS-), and were maintained under HQ alone during a mean follow-up of 6.2 ± 3 years. In this group, an ICD was eventually implanted in four patients (12%), with occurrence of appropriate ICD therapies in one. Among the 10 other patients (22%), who remained inducible and received ICD (Group PVS+), none of them received appropriate therapy during a mean follow-up of 7.7 ± 2 years. The overall annual rate of arrhythmic events was 1.04% (95% confidence interval 0.00-2.21), without any significant difference according to the result of PVS under HQ. One-third of patients experienced device-related complications.Conclusion: Our long-term follow-up results emphasize that the rate of arrhythmic events among asymptomatic Brugada patients with inducible VF remains low over time. Our results also suggest that residual inducibility under HQ is of limited value to predict events during follow-up.

Europace: 25 Sep 2013; epub ahead of print
Bouzeman A, Traulle S, Messali A, Extramiana F, ... Hermida JS, Leenhardt A
Europace: 25 Sep 2013; epub ahead of print | PMID: 24068450
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Abstract

Preferred tools and techniques for implantation of cardiac electronic devices in Europe: results of the European Heart Rhythm Association survey.

Bongiorni MG, Proclemer A, Dobreanu D, Marinskis G, ... conducted by the Scientific Initiative Committee, European Heart Rhythm Association
The aim of this European Heart Rhythm Association (EHRA) survey was to assess clinical practice in relation to the tools and techniques used for cardiac implantable electronic devices procedures in the European countries. Responses to the questionnaire were received from 62 members of the EHRA research network. The survey involved high-, medium-, and low-volume implanting centres, performing, respectively, more than 200, 100-199 and under 100 implants per year. The following topics were explored: the side approach for implantation, surgical techniques for pocket incision, first venous access for lead implantation, preference of lead fixation, preferred coil number for implantable cardioverter-defibrillator (ICD) leads, right ventricular pacing site, generator placement site, subcutaneous ICD implantation, specific tools and techniques for cardiac resynchronization therapy (CRT), lead implantation sequence in CRT, coronary sinus cannulation technique, target site for left ventricular lead placement, strategy in left ventricular lead implant failure, mean CRT implantation time, optimization of the atrioventricular (AV) and ventriculo-ventricular intervals, CRT implants in patients with permanent atrial fibrillation, AV node ablation in patients with permanent AF. This panoramic view allows us to find out the operator preferences regarding the techniques and tools for device implantation in Europe. The results showed different practices in all the fields we investigated, nevertheless the survey also outlines a good adherence to the common standards and recommendations.

Europace: 29 Oct 2013; 15:1664-8
Bongiorni MG, Proclemer A, Dobreanu D, Marinskis G, ... conducted by the Scientific Initiative Committee, European Heart Rhythm Association
Europace: 29 Oct 2013; 15:1664-8 | PMID: 24170423
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Abstract

Increased risk of atrial fibrillation and stroke during active stages of inflammatory bowel disease: a nationwide study.

Kristensen SL, Lindhardsen J, Ahlehoff O, Erichsen R, ... Gislason GH, Hansen PR
Inflammation is considered to play a role in the development of atrial fibrillation (AF). Hence inflammatory bowel disease (IBD) may be associated with AF. We therefore examined the incidence of AF and stroke in patients with IBD.Methods and results: From Danish nationwide registries 1996-2011, we identified 24 499 patients with new-onset IBD and 236 275 age- and sex-matched controls. Poisson regression analyses with continuously updated covariates were used to estimate incidence rate ratios (IRRs) of AF and stroke. Disease activity stages of flare (new disease activity), persistent activity, and remission were defined by corticosteroid prescriptions, IBD hospital admissions, and biological treatment. Inflammatory bowel disease patients had a mean age of 43.9 years, 53.9% were women, and mean follow-up was 6.8 years. Among IBD patients, 685 had AF and 549 had a stroke, corresponding to incidence rates per 1000 person-years of 4.16 vs. 2.70 for AF and 3.33 vs. 2.44 for stroke, compared with matched controls. Overall IBD-associated risk of AF corresponded to IRR 1.26 (1.16-1.36), but was driven by increased AF incidence during IBD flares [IRR 2.63 (2.26-3.06)] and persistent activity [IRR 2.06 (1.67-2.55)], whereas no increased AF risk was observed in remission periods [IRR 0.97 (0.88-1.08)]. Likewise increased stroke risk was exclusively found during active IBD [IRRs: 1.57 (1.27-1.93), 1.71 (1.32-2.21), and 1.04 (0.93-1.15) for flares, persistent activity, and remission, respectively].Conclusion: Active IBD is associated with increased risk of AF and stroke. These findings may be relevant to clinical practice.

Europace: 09 Oct 2013; epub ahead of print
Kristensen SL, Lindhardsen J, Ahlehoff O, Erichsen R, ... Gislason GH, Hansen PR
Europace: 09 Oct 2013; epub ahead of print | PMID: 24108228
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Abstract

Role of electrical storm as a mortality and morbidity risk factor and its clinical predictors: a meta-analysis.

Guerra F, Shkoza M, Scappini L, Flori M, Capucci A
Electrical storm (ES) is a devastating and life-threatening event in clinical practice, but its real weight as a risk factor and its clinical predictors remain unclear. Our objective was to evaluate ES as a mortality and morbidity risk factor and to define the clinical variables associated with ES.Methods and results: The meta-analysis was performed according to the PRISMA guidelines. At the end of the selection process, 13 studies were collected and included in the quantitative analysis. Mortality and morbidity due to ES were assessed. The most acknowledged ES predictors were taken into account in separate sub-analyses. The whole cohort included 5912 patients (857 with ES). Risk of death was increased in the ES group [risk ratio (RR) 3.15; 95% confidence interval (CI) 2.22-4.48]. Electrical storm was also associated with increased composite risk of all-cause death, cardiac transplantation, and hospitalization for acute heart failure (RR 3.39; 95% CI 2.31-4.97). These results were confirmed by comparing the ES group with patients with or without previous unclustered episodes of ventricular arrhythmias. Moreover, implantable cardioverter-defibrillator (ICD) for secondary prevention, lower ejection fraction, monomorphic ventricular tachycardia as triggering arrhythmia, and class I anti-arrhythmic drugs therapy were all associated with ES.Conclusion: Electrical storm is a strong mortality risk factor and it is associated with an increased combined risk of death, heart transplantation, and hospitalization for heart failure. Implantable cardioverter-defibrillator for secondary prevention, monomorphic ventricular tachycardia as triggering arrhythmia, lower ejection fraction, and class I anti-arrhythmic drugs therapy are all associated with ES and could be used to define specific populations with higher risk to develop ES.

Europace: 06 Oct 2013; epub ahead of print
Guerra F, Shkoza M, Scappini L, Flori M, Capucci A
Europace: 06 Oct 2013; epub ahead of print | PMID: 24096960
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Abstract

How are patients with atrial fibrillation approached and informed about their risk profile and available therapies in Europe? Results of the European Heart Rhythm Association Survey.

Potpara TS, Pison L, Larsen TB, Estner H, ... and European Heart Rhythm Association, Conducted by the Scientific Initiatives Committee and European Heart Rhythm Association
This European Heart Rhythm (EHRA) Scientific Initiatives Committee EP Wire Survey aimed at exploring the common practices in approaching patients with atrial fibrillation (AF) and informing them about their risk profiles and available therapies in Europe. In the majority of 53 responding centres, patients were seen by cardiologists (86.8%) or arrhythmologists (64.2%). First- and follow-up visits most commonly lasted 21-30 and 11-20 min (41.5 and 69.8% of centres, respectively). In most centres (80.2%) stroke and bleeding risk had the highest priority for discussion with AF patients; 50.9% of centres had a structured patient education programme for stroke prevention. Individual patient stroke risk was assessed at every visit in 69.2% of the centres; 46.1% of centres had a hospital-based anticoagulation clinic. Information about non-vitamin K oral anticoagulants (NOACs) was communicated to all AF patients eligible for oral anticoagulation (38.5% of centres) or to warfarin-naive/unstable patients (42.3%). Only two centres (3.8%) had a structured NOAC adherence follow-up programme; in eight centres (15.4%) patients were requested to sign the statement they have been informed about the risks of non-adherence to NOAC therapy, and three centres (5.8%) had a patient education programme. Patient preferences were of the highest relevance regarding oral anticoagulation and AF ablation (64.7 and 49.0% of centres, respectively). This EP Wire Survey shows that in Europe considerable amount of time and resources are used in daily clinical practice to inform AF patients about their risk profile and available therapies. However, a diversity of strategies used across the European hospitals was noted, and further research is needed to better define optimal strategies for informing AF patients about their risk profile and treatment options.

Europace: 26 Feb 2015; 17:468-72
Potpara TS, Pison L, Larsen TB, Estner H, ... and European Heart Rhythm Association, Conducted by the Scientific Initiatives Committee and European Heart Rhythm Association
Europace: 26 Feb 2015; 17:468-72 | PMID: 25722478
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Abstract

Navigated DENSE strain imaging for post-radiofrequency ablation lesion assessment in the swine left atria.

Schmidt EJ, Fung MM, Ciris PA, Song T, ... Aletras AH, Danik SB
Prior work has demonstrated that magnetic resonance imaging (MRI) strain can separate necrotic/stunned myocardium from healthy myocardium in the left ventricle (LV). We surmised that high-resolution MRI strain, using navigator-echo-triggered DENSE, could differentiate radiofrequency ablated tissue around the pulmonary vein (PV) from tissue that had not been damaged by radiofrequency energy, similarly to navigated 3D myocardial delayed enhancement (3D-MDE).Methods and results: A respiratory-navigated 2D-DENSE sequence was developed, providing strain encoding in two spatial directions with 1.2 × 1.0 × 4 mm(3) resolution. It was tested in the LV of infarcted sheep. In four swine, incomplete circumferential lesions were created around the right superior pulmonary vein (RSPV) using ablation catheters, recorded with electro-anatomic mapping, and imaged 1 h later using atrial-diastolic DENSE and 3D-MDE at the left atrium/RSPV junction. DENSE detected ablation gaps (regions with >12% strain) in similar positions to 3D-MDE (2D cross-correlation 0.89 ± 0.05). Low-strain (<8%) areas were, on average, 33% larger than equivalent MDE regions, so they include both injured and necrotic regions. Optimal DENSE orientation was perpendicular to the PV trunk, with high shear strain in adjacent viable tissue appearing as a sensitive marker of ablation lesions.Conclusions: Magnetic resonance imaging strain may be a non-contrast alternative to 3D-MDE in intra-procedural monitoring of atrial ablation lesions.

Europace: 08 Sep 2013; epub ahead of print
Schmidt EJ, Fung MM, Ciris PA, Song T, ... Aletras AH, Danik SB
Europace: 08 Sep 2013; epub ahead of print | PMID: 24014803
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Abstract

Pocket infections of cardiac implantable electronic devices treated by negative pressure wound therapy.

McGarry TJ, Joshi R, Kawata H, Patel J, ... Birgersdotter-Green UM, Pretorius V
Managing an infection of the pocket of a cardiac implantable electronic device (CIED) is frequently challenging. The wound is often treated with a drain or wet-to-dry dressings that allow healing by secondary intention. Such treatment can prolong the hospital stay and can frequently result in a disfiguring scar. Negative pressure wound therapy (NPWT) has been frequently used to promote the healing of chronic or infected surgical wounds. Here we describe the first series of 28 patients in which NPWT was successfully used to treat CIED pocket infections.Methods and results: After removal of the CIED and debridement of the pocket, a negative pressure of 125 mmHg continuously applied to the wound through an occlusive dressing. Negative pressure wound therapy was continued for a median of 5 days (range 2-15 days) and drained an average of 260 mL sero-sanguineous fluid (range 35-970 mL). At the conclusion of NPWT, delayed primary closure of the pocket was performed with 1-0 prolene mattress sutures. The median length of stay after CIED extraction was 11.0 days (range 2-43 days). Virtually all infected pockets healed without complications and without evidence of recurrent infection over a median follow-up of 49 days (range 10-752 days). One patient developed a recurrent infection when NPWT was discontinued prematurely and a new device was implanted at the infected site.Conclusion: We conclude that NPWT is a safe and effective means to promote healing of infected pockets with a low incidence of recurrent infection and a satisfactory cosmetic result.

Europace: 14 Oct 2013; epub ahead of print
McGarry TJ, Joshi R, Kawata H, Patel J, ... Birgersdotter-Green UM, Pretorius V
Europace: 14 Oct 2013; epub ahead of print | PMID: 24127355
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Abstract

The effect of a nurse-led integrated chronic care approach on quality of life in patients with atrial fibrillation.

Hendriks JM, Vrijhoef HJ, Crijns HJ, Brunner-La Rocca HP
Quality of life (QoL) is often impaired in patients with atrial fibrillation (AF). A novel nurse-led integrated chronic care approach demonstrated superiority compared with usual care in terms of cardiovascular hospitalization and mortality. Consequently, we hypothesized that this approach may also improve QoL and AF-related knowledge, which in turn may positively correlate with QoL.Methods and results: In this randomized controlled trial, 712 patients were randomly assigned to nurse-led care vs. usual care. Nurse-led care consisted of guidelines-based, software supported care, supervised by cardiologists. Usual care was provided by cardiologists in the regular outpatient setting. Quality of life was assessed by means of the Medical Outcomes Study 36-Item Short-Form Survey (SF-36). The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression scores. The AF knowledge scale was used to gain an insight into the patients\' AF knowledge levels. Baseline QoL scores were relatively high in both groups, with median scores ranging from 55 to 100. Quality of life significantly improved over time in both groups with no significant differences between the two groups. Atrial fibrillation-related knowledge improved over time and was significantly higher at follow-up in the intervention group, compared with the usual care group (8.23 ± 2.16 vs. 7.66 ± 2.09; P < 0.05). Quality of life was correlated with gender (rs: -5.819 to -2.960), anxiety (rs: -0.746 to -0.277), depression (rs: -0.596 to -0.395), and knowledge (rs: 0.145-0.245), expressed in Spearman\'s rank correlation coefficient (rs).Conclusion: Quality of life including anxiety and depression improved over time, regardless of the treatment group. The AF-related knowledge level was better in the nurse-led care group at follow-up. Trial registration information: Clinicaltrials.gov identifier number: NCT00753259.

Europace: 22 Sep 2013; epub ahead of print
Hendriks JM, Vrijhoef HJ, Crijns HJ, Brunner-La Rocca HP
Europace: 22 Sep 2013; epub ahead of print | PMID: 24058179
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Abstract

Comparison of CHADS2 and CHA2DS2-VASC anticoagulation recommendations: evaluation in a cohort of atrial fibrillation ablation patients.

Winkle RA, Mead RH, Engel G, Kong MH, Patrawala RA
Atrial fibrillation (AF) is associated with a high incidence of strokes/thromboembolism. The CHADS2 score assigns points for several clinical variables to identify stroke risk. The CHA2DS2-VASC score uses the same variables but also incorporates age 65 to 74, female gender, and vascular disease in an effort to provide a more refined risk of stroke/thromboembolism. We aimed to examine oral anticoagulation (OAC) recommendations for a cohort of patients undergoing AF ablation depending upon whether thrombo-embolic risk was determined by the CHADS2 or CHA2DS2-VASC score.Methods and results: For 1411 patients we compared OAC recommendations for each of these risk stratification schemes to one of the three OAC strategies: (i) NO-OAC, (ii) CONSIDER-OAC, and (iii) DEFINITE-OAC. Compared with the CHADS2 score, the CHA2DS2-VASC score reduced NO-OAC from 40.3 to 21.8% and CONSIDER-OAC from 36.6 to 27.9% while increasing DEFINITE-OAC from 23.0 to 50.2% of patients. Age 65 to 74 and female gender accounted for 95.2% and vascular disease for only 4.8% of recommendations for more aggressive OAC using CHA2DS2-VASC. Most vascular disease occurred in patients with higher CHADS2 scores already recommended for DEFINITE-OAC (P < 0.0001). Reclassifying 30 females of age <65 with a CHA2DS2-VASC score of 1 to the NO-OAC group had minimal effect on the overall recommendations.Conclusion: Compared with the CHADS2 score, in our AF ablation population, the CHA2DS2-VASC score markedly increases the number of AF patients for whom OAC is recommended. It will be important to determine by randomized trials if this major paradigm shift to greater use of OAC using the CHA2DS2-VASC scoring improves patient outcomes.

Europace: 15 Sep 2013; epub ahead of print
Winkle RA, Mead RH, Engel G, Kong MH, Patrawala RA
Europace: 15 Sep 2013; epub ahead of print | PMID: 24036378
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Abstract

Role of extended external loop recorders for the diagnosis of unexplained syncope, pre-syncope, and sustained palpitations.

Locati ET, Vecchi AM, Vargiu S, Cattafi G, Lunati M
To assess the diagnostic yield of new external loop recorders (ELRs) in patients with history of syncope, pre-syncope, and sustained palpitations.Methods and results: Since 2005, we have established a registry including patients who consecutively received ELR monitoring for unexplained syncope or pre-syncope/palpitations. The registry included 307 patients (61% females, age 58 ± 19 years, range 8-94 years) monitored by high-capacity memory ELR of two subsequent generations: SpiderFlash-A(®) (SFA(®), Sorin CRM), storing two-lead electrocardiogram (ECG) patient-activated recordings by loop-recording technique (191 patients, 54 patients with syncope, years 2005-09), and SpiderFlash-T(®) (SFT(®)), adding auto-trigger detection for pauses, bradycardia, and supraventricular/ventricular arrhythmias (116 patients, 38 patients with syncope, years 2009-12). All the patients previously underwent routine workup for syncope or palpitation, including one or more 24 h Holter, not conclusive for diagnosis. Mean monitoring duration was 24.1 ± 8.9 days. Among 215 patients with palpitations, a conclusive diagnosis was obtained in 184 patients (86% diagnostic yield for palpitation). Among 92 patients with syncope, a conclusive diagnosis was obtained in 16 patients (17% clinical diagnostic yield for syncope), with recording during syncope of significant arrhythmias in 9 patients, and sinus rhythm in 7 patients. Furthermore, asymptomatic arrhythmias were de novo detected in 12 patients (13%), mainly by auto-trigger detection, suggesting an arrhythmic origin of the syncope.Conclusions: The diagnostic yield of ELR in patients with syncope, pre-syncope, or palpitation of unknown origin after routine workup was similar to implantable loop recorder (ILR) within the same timeframe, therefore, ELR could be considered for patients candidate for long-term ECG monitoring, stepwise before ILR.

Europace: 24 Oct 2013; epub ahead of print
Locati ET, Vecchi AM, Vargiu S, Cattafi G, Lunati M
Europace: 24 Oct 2013; epub ahead of print | PMID: 24158255
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Abstract

Modified phased radiofrequency ablation of atrial fibrillation reduces the number of cerebral microembolic signals.

Zellerhoff S, Ritter MA, Kochhäuser S, Dittrich R, ... Eckardt L, Mönnig G
Phased radiofrequency (RF) ablation for atrial fibrillation is associated with an increased number of silent cerebral lesions on magnetic resonance imaging and cerebral microembolic signals (MESs) on transcranial Doppler ultrasound imaging compared with irrigated RF. The increased rate of embolic events may be due to a specific electrical interference of ablation electrodes attributed to the catheter design. The purpose of this study was to elucidate the effect of deactivating the culprit electrodes on cerebral MESs.Methods and results: Twenty-nine consecutive patients (60 ± 11 years, 10 female) underwent their first pulmonary vein isolation using phased RF energy. Electrode pairs 1 or 5 were deactivated to avoid electrical interference between electrodes 1 and 10 (\'modified\'). Detection of MESs by transcranial Doppler ultrasound was performed throughout the procedure to assess cerebral microembolism. Results were compared with the numbers of MESs in 31 patients ablated using all available electrodes (\'conventional\') and to 30 patients undergoing irrigated RF ablation of a previous randomized study. Ablation with \'modified\' phased RF was associated with a marked decrease in MESs when compared with \'conventional\' phased RF (566 ± 332 vs. 1530 ± 980; P < 0.001). This difference was mainly triggered by the reduction of MES during delivery of phased RF energy, resulting in MES numbers comparable to irrigated RF ablation (646 ± 449; P = 0.7). Total procedure duration as well as time of RF delivery was comparable between phased RF groups. Both times, however, were significantly shorter compared with the irrigated RF group (123 ± 28 vs. 195 ± 38; 15 ± 4 vs. 30 ± 9; P < 0.001, respectively).Conclusion: Pulmonary vein isolation with \'modified\' phased RF is associated with a decreased number of cerebral microembolism especially during the delivery of ablation impulses, supporting the significance of electrical interference between ablation electrodes 1 and 10. Deactivation of electrode pairs 1 or 5 might increase the safety of this approach without an increase in procedure duration or RF delivery time.

Europace: 26 Sep 2013; epub ahead of print
Zellerhoff S, Ritter MA, Kochhäuser S, Dittrich R, ... Eckardt L, Mönnig G
Europace: 26 Sep 2013; epub ahead of print | PMID: 24072443
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Abstract

Clinical context and outcome of carotid sinus syndrome diagnosed by means of the \'method of symptoms\'

Solari D, Maggi R, Oddone D, Solano A, ... Donateo P, Brignole M
The prevalence and outcome of carotid sinus syndrome (CSS) reported in the literature vary owing to differences in indications and methods of carotid sinus massage (CSM).Methods and results: We performed CSM on all patients aged 40 years and above with unexplained syncope after the initial evaluation. Carotid sinus massage was performed in the supine and standing positions on both sides for 10 s during continuous electrocardiogram and blood pressure monitoring; CSS was diagnosed in the event of an abnormal response to CSM in association with reproduction of spontaneous symptoms (\'method of symptoms\'). From July 2005 to July 2012, CSS was found in 164 (8.8%) of 1855 patients (mean age 77 ± 9 years, 73% males): 81% had an asystolic reflex (mean pause 7.6 ± 2.2 s) and 19% a vasodepressor reflex (mean lowest systolic blood pressure 65 ± 15 mmHg). Potential multifactorial causes of syncope (orthostatic hypotension, bundle branch block, bradycardia, tachyarrhythmias) were found in 74% of patients. One hundred forty-one patients received the proper care [advice on lifestyle measures in all, discontinuation (#40) or reduction (#17) of antihypertensive drugs, pacemaker implantation (#57)] and were followed up for 39 ± 25 months. Syncope recurred in 23 patients; the actuarial syncopal recurrence rate was 7% at 1 year and 26% at 5 years. Total syncopal episodes decreased from 91 per year during the 2 years before evaluation to 21 episodes per year during follow-up (P = 0.001). On Cox proportional-hazards regression, a mixed or vasodepressor response to tilt testing was the only independent predictor of syncopal recurrence (hazard ratio = 1.8; P = 0.01).Conclusion: Carotid sinus massage by means of the \'method of symptoms\' indentifies a clinical syndrome with definite features and outcome. A treatment strategy involving lifestyle measures, reduction of antihypertensive drugs and cardiac pacing when appropriate is effective in reducing the syncopal recurrence rate.

Europace: 22 Sep 2013; epub ahead of print
Solari D, Maggi R, Oddone D, Solano A, ... Donateo P, Brignole M
Europace: 22 Sep 2013; epub ahead of print | PMID: 24058183
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Abstract

Uric acid is associated with future atrial fibrillation: an 11-year follow-up of 6308 men and women--the Tromso Study.

Nyrnes A, Toft I, Njølstad I, Mathiesen EB, ... Hansen JB, Løchen ML
Serum uric acid (SUA) has been associated with cardiovascular disease in population studies, but its relation to atrial fibrillation (AF) is largely unknown. The aim of this study was to investigate the association between baseline SUA and future AF in a large population-based cohort.Methods and results: A total of 6308 men and women from a population survey in Tromsø, Norway in 1994-95 were followed-up for 10.8 years. The mean age at baseline was 60 years. Information on angina, myocardial infarction, diabetes, anti-hypertensive and diuretic treatment, physical activity, smoking and alcohol, and measurements of height, weight, blood pressure, SUA, total cholesterol, and high density lipoprotein-cholesterol were obtained at baseline. The outcome measure was first-ever AF, documented on an electrocardiogram. We identified 572 cases of incident AF. In multivariable Cox proportional hazards regression analysis adjusted for cardiovascular risk factors and concomitant diseases, SUA was associated with AF in both sexes. Hazard ratio per 1 SD increase in SUA (91 μmol/L) was 1.40 [95% confidence intervals (CI), 1.14-1.72] in women and 1.17 (95% CI, 1.02-1.36) in men. The upper quartile of SUA conferred a 76% increased risk for AF in women and 49% in men as compared with the lowest quartile.Conclusion: This prospective population-based cohort study showed that baseline SUA was associated with an increased risk for future AF in both sexes.

Europace: 01 Sep 2013; epub ahead of print
Nyrnes A, Toft I, Njølstad I, Mathiesen EB, ... Hansen JB, Løchen ML
Europace: 01 Sep 2013; epub ahead of print | PMID: 23994780
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Abstract

Correlation of intracardiac electrogram with surface electrocardiogram in Brugada syndrome patients.

Probst V, Sacher F, Derval N, Gourraud JB, ... Le Marec H, Gill J
The objective of this study was to correlate the electrocardiogram (ECG) modification during an Ajmaline challenge in patients affected by the Brugada syndrome and implanted with an implantable cardioverter-defibrillator (ICD) with the morphological changes of their ICD\'s intracardiac electrogram (IEGM).Methods and results: Sixteen type 1 Brugada syndrome patients implanted with a St Jude Medical AnalyST(®) ICD were enrolled and underwent ajmaline challenge. Intracardiac electrograms and 12 lead ECG signals were collected over the duration of the study and analysed off-line. The right precordial ECG leads were in both the third and fourth intercostal space by putting V5 and V6 in V1 and V2 at the third intercostal space. Two patients were excluded from the analysis due to signal noise issues. Of the remaining 14 patients, 12 and 2 patients were adjudicated to have positive and negative ajmaline challenges, respectively, based on standard ECG criteria. In the ajmaline positive patients, the IEGM T wave amplitude changes were more prominent than those of the IEGM ST segment (-898 ± 463 vs. -55 ± 381 µV, P < 0.05). Furthermore, all of these T wave amplitude changes were in the negative polarity, whereas the change in polarity of the ST segment was mixed. The changes in the IEGM T wave amplitude and ST segment were significantly smaller in the ajmaline negative patients compared with those in the ajmaline positive patients [211 ± 158 (P < 0.05) and 107 ± 54 (P < 0.05) µV, respectively). Over all 14 analysable patients, the change in the ECG ST segment over the timecourse of the ajmaline challenge correlated better with the IEGM T wave amplitude change (R = 0.72 ± 0.33) than the IEGM ST segment change (R = 0.63 ± 0.33). Applying an IEGM T wave amplitude change cut-off of 400 µV for predicting the outcome of the ajmaline challenge yielded 92% sensitivity (11/12) and 100% specificity (2/2).Conclusion: In Brugada patients, ajmaline challenge elicits significant T wave amplitude changes within the ICD IEGM, greater than those of the IEGM ST segment. This study is the first step to provide new tools able to continuously monitor the type I Brugada aspect in patients affected by the Brugada syndrome.

Europace: 25 Sep 2013; epub ahead of print
Probst V, Sacher F, Derval N, Gourraud JB, ... Le Marec H, Gill J
Europace: 25 Sep 2013; epub ahead of print | PMID: 24068444
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Abstract

Applicability of the iterative technique for cardiac resynchronization therapy optimization: full-disclosure, 50-sequential-patient dataset of transmitral Doppler traces, with implications for future research design and guidelines.

Jones S, Shun-Shin MJ, Cole GD, Sau A, ... Whinnett ZI, Francis DP
Full-disclosure study describing Doppler patterns during iterative atrioventricular delay (AVD) optimization of biventricular pacemakers (cardiac resynchronization therapy, CRT).METHOD AND Results: Doppler traces of the first 50 eligible patients undergoing iterative Doppler AVD optimization in the BRAVO trial were examined. Three experienced observers classified conformity to guideline-described patterns. Each observer then selected the optimum AVD on two separate occasions: blinded and unblinded to AVD. Four Doppler E-A patterns occurred: A (always merged, 18% of patients), B (incrementally less fusion at short AVDs, 12%), C (full separation at short AVDs, as described by the guidelines, 28%), and D (always separated, 42%). In Groups A and D (60%), the iterative guidelines therefore cannot specify one single AVD. On the kappa scale (0 = chance alone; 1 = perfect agreement), observer agreement for the ideal AVD in Classes B and C was poor (0.32) and appeared worse in Groups A and D (0.22). Blinding caused the scattering of the AVD selected as optimal to widen (standard deviation rising from 37 to 49 ms, P < 0.001). By blinding 28% of the selected optimum AVDs were ≤60 or ≥200 ms. All 50 Doppler datasets are presented, to support future methodological testing.Conclusion: In most patients, the iterative method does not clearly specify one AVD. In all the patients, agreement on the ideal AVD between skilled observers viewing identical images is poor. The iterative protocol may successfully exclude some extremely unsuitable AVDs, but so might simply accepting factory default. Irreproducibility of the gold standard also prevents alternative physiological optimization methods from being validated honestly.

Europace: 25 Sep 2013; epub ahead of print
Jones S, Shun-Shin MJ, Cole GD, Sau A, ... Whinnett ZI, Francis DP
Europace: 25 Sep 2013; epub ahead of print | PMID: 24068445
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Abstract

Scar extent as a predictive factor of ventricular tachycardia cycle length after myocardial infarction: implications for implantable cardioverter-defibrillator programming optimization.

Alexandre J, Saloux E, Lebon A, Dugué AE, ... Scanu P, Milliez P
After an old myocardial infarction (MI), patients are at risk for reentrant ventricular tachycardia (VT) due to scar tissue that can be accurately identified by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Although the ability of LGE-CMR to predict sustained VT in implantable cardioverter-defibrillator (ICD) recipients has been well established, its use to predict monomorphic VT (sustained or not) cycle length (CL) and so, optimize ICD programming has never been investigated.Methods and results: We included retrospectively 49 consecutive patients with an old MI who had undergone LGE-CMR before ICD implantation over a 4-year period (2006-09). Patients with amiodarone used were excluded. Scar extent was assessed by measuring scar mass, percent scar, and transmural scar extent. The endpoint was the occurrence of monomorphic VT, requiring an ICD therapy or not. The endpoint occurred in 26 patients. The median follow-up duration was 31 months. Scar extent parameters were significantly correlated with the study endpoint. With univariate regression analysis, the scar mass had the highest correlation with the VT CL (R = 0.671, P = 0.0002). Receiver-operating characteristic curve showed that scar mass can predict VT CL (area under the curve = 0.977, P < 0.0001). For a cut-off value of scar mass at 17.6 g, there is 100% specificity and 94.4% sensitivity.Conclusion: In this observational and retrospective study, scar mass studied by LGE-CMR was specific and sensitive to predict VT CL and so could be a promising option to improve ICD post-implantation programming and decrease appropriate and inappropriate shocks. These conclusions must now be confirmed in a large and prospective study.

Europace: 03 Nov 2013; epub ahead of print
Alexandre J, Saloux E, Lebon A, Dugué AE, ... Scanu P, Milliez P
Europace: 03 Nov 2013; epub ahead of print | PMID: 24186956
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Abstract

How are arrhythmias managed in the paediatric population in Europe? Results of the European Heart Rhythm survey.

Hernández-Madrid A, Hocini M, Chen J, Potpara T, ... conducted by the Scientific Initiative Committee, European Heart Rhythm Association
The aim of this survey was to provide insight into current practice regarding the management of paediatric arrhythmias in Europe. The survey was based on a questionnaire sent via the Internet to the European Heart Rhythm Association (EHRA) electrophysiology research network centres. The following topics were explored: patient and treatment selection, techniques and equipment, treatment outcomes and complications. The vast majority of paediatric arrhythmias concerns children older than 1 year and patients with grown-up congenital heart disease. In 65% of the hospitals there is a specialized paediatric centre, and the most commonly observed arrhythmias include Wolff-Parkinson-White syndrome and atrioventricular nodal re-entry tachycardias (90.24%). The medical staff performing paediatric catheter ablations in Europe are mainly adult electrophysiology teams (82.05% of the centres). Radiofrequency is the preferred energy source used for paediatric arrhythmia ablation. Catheter ablation is only chosen if two or more antiarrhythmic drugs have failed (94.59% of the centres). The majority of the centres use flecainide (37.8%) or atenolol (32.4%) as their first choice drug for prevention of recurrent supraventricular arrhythmias. While none of the centres performed catheter ablation in asymptomatic infants with pre-excitation, 29.7% recommend ablation in asymptomatic children and adolescents. The preferred choice for pacemaker leads in infants less than 1 year old is implantation of epicardial leads in 97.3% of the centres, which continues to be the routine even in patients between 1 and 5 years of age as reported by 75.68% of the hospitals. Almost all centres (94.59%) report equally small number of complications of catheter ablation in children (aged 1-14 years) as observed in adults.

Europace: 23 Nov 2014; 16:1852-6
Hernández-Madrid A, Hocini M, Chen J, Potpara T, ... conducted by the Scientific Initiative Committee, European Heart Rhythm Association
Europace: 23 Nov 2014; 16:1852-6 | PMID: 25417228
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Abstract

Ivabradine in treatment of sinus tachycardia mediated vasovagal syncope.

Sutton R, Salukhe TV, Franzen-McManus AC, Collins A, Lim PB, Francis DP
Ivabradine, an I(f) current blocker, has shown promising results in treatment of postural orthostatic tachycardia syndrome (POTS). There is a subgroup of vasovagal syncope (VVS) patients, who demonstrate sinus tachycardia before collapse on tilt testing mimicking some features of POTS. These patients may also respond to ivabradine therapy.University Hospital Syncope Clinic where ivabradine was prescribed in a prospective fashion on humanitarian grounds between October 2008 and December 2011.Methods and results: Twenty-five patients of mean age 33±years presenting syncope in all and palpitation in 23, duration 9±years underwent tilt testing with reproduction of usual symptoms including tachycardia preceding collapse. Ivabradine was prescribed in doses of 5-20 mg/day, mean 10.7 mg, as once or twice daily medication. The response to treatment was classified as deterioration in none, no change in 5, improvement in 10, and symptoms abolished in 8 patients. Side effects were minimal; one patient required discontinuation.Conclusion: In this pilot study of ivabradine, in patients with VVS, of patients who demonstrated sinus tachycardia before collapse on tilt, 72% reported a marked benefit or complete resolution of symptoms. The drug was well tolerated. A randomized controlled trial against placebo is justified.

Europace: 26 Sep 2013; epub ahead of print
Sutton R, Salukhe TV, Franzen-McManus AC, Collins A, Lim PB, Francis DP
Europace: 26 Sep 2013; epub ahead of print | PMID: 24072450
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Abstract

Do implantable cardioverter defibrillators improve survival in patients with chronic kidney disease at high risk of sudden cardiac death? A meta-analysis of observational studies.

Makki N, Swaminathan PD, Hanmer J, Olshansky B
Prospective randomized clinical trials show that implantable cardioverter defibrillators (ICDs) can reduce the risk of total mortality in select populations. However, data regarding patients with chronic kidney disease (CKD) are inconclusive. The aim of this study was to evaluate if ICDs affect total mortality in CKD patients at high risk of sudden cardiac death.Methods and results: Two separate meta-analyses were performed to (i) assess the effect of ICD on all-cause mortality in CKD patients at high risk of sudden cardiac death and (ii) assess the effect of CKD on all-cause mortality in patients who already had an ICD for primary or secondary prevention purposes. Medline and EMBASE were searched from 1966 to 2013. A manual search by cross-referencing was performed. Five observational studies with 17 460 CKD patients considered at high risk of sudden cardiac death were included to evaluate the effect of ICDs on patients with severe CKD. Patients with ICD implants had a reduction in all-cause mortality (adjusted hazard ratio (HR) = 0.65, 95% confidence interval (CI) = 0.47-0.91, P < 0.05) compared with a matched control group. Based on 15 observational studies with 5233 patients as part of our second comparison that evaluated the effect of CKD on patients who received an ICD, CKD was associated with higher mortality risk (HR = 2.86, 95% CI = 1.91-4.27, P < 0.05) despite an ICD.Conclusion: The meta-analysis indicates that for patients undergoing ICD implant, CKD is associated with greater risk of dying. However, ICD placement reduces mortality in CKD patients at high risk of sudden cardiac death.

Europace: 22 Sep 2013; epub ahead of print
Makki N, Swaminathan PD, Hanmer J, Olshansky B
Europace: 22 Sep 2013; epub ahead of print | PMID: 24058182
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Safety and efficacy of strategic implantable cardioverter-defibrillator programming to reduce the shock delivery burden in a primary prevention patient population.

Buber J, Luria D, Gurevitz O, Bar-Lev D, Eldar M, Glikson M
Strategically chosen ventricular tachycardia (VT)/ventricular fibrillation (VF) detection and therapy parameters aimed at reducing shock deliveries were proven effective in studies that utilized single manufacturer devices with a follow-up of up to 1 year. Whether these beneficiary effects can be generalized to additional manufacturers and be maintained for longer periods is to be determined. Our aim was to evaluate the durability and applicability of the programming of strategic implantable cardioverter-defibrillators (ICDs) of various manufacturers, which is aimed at reducing the shock delivery burden in primary prevention ICD recipients.Methods and results: A retrospective analysis of prospectively collected data of 300 ICD recipients of various manufacturers was conducted; 160 devices were strategically programmed to reduce shocks and 140 were not. The primary endpoint was the composite of death and appropriate shocks. Additional outcomes were inappropriate shocks, syncope events, and non-sustained VTs. At a median follow-up of 24 months, 19 patients died, 31 received appropriate shocks, and 41 received inappropriate shocks. Multivariate analysis showed that strategic programming dedicated to shock reduction was associated with a 64% risk reduction in the primary endpoint [hazard ratio (HR): 0.13-0.93; P = 0.03] and a 70% reduction in inappropriate shock deliveries (HR: 0.16-0.72; P = 0.01). Very few syncope events occurred (five patients, 1.6%), and there was no between-group difference in this outcome.Conclusion: Utilization of strategically chosen VT/VF detection and therapy parameters was found to be effective and safe in ICDs of various manufacturers at a median follow-up period of 2 years among primary prevention patients.

Europace: 09 Oct 2013; epub ahead of print
Buber J, Luria D, Gurevitz O, Bar-Lev D, Eldar M, Glikson M
Europace: 09 Oct 2013; epub ahead of print | PMID: 24108231
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Abstract

Systematic fluoroscopic and electrical assessment of implantable cardioverter-defibrillator patients implanted with silicone-polyurethane copolymer (Optim™) coated leads.

Forleo GB, Di Biase L, Panattoni G, Politano A, ... Natale A, Romeo F
Serious concerns have been recently raised about the reliability of the silicone-polyurethane copolymer (Optim™) lead insulation system. We sought to identify insulation defects and Optim-lead failures by systematic fluoroscopic and electrical assessment in a prospectively defined cohort of implantable cardioverter-defibrillator (ICD) patients.Methods and results: Between July 2007 and December 2011, 234 patients were implanted with 413 optim-coated leads as part of an ICD system at a single centre. Fluoroscopic screening with high-resolution cine-fluoroscopy at 30 frames per second was offered to all patients. In addition, the electrical integrity of all implanted leads was assessed. Durata, Riata ST Optim, and low-voltage Optim leads were implanted in 199, 26, and 188 cases, respectively. During a total follow-up of 10 036 lead-months, there were 7 Optim-lead failures (defined as electrical malfunction resulting in lead replacement) and 31 deaths; no cases of electrical noises were encountered. The overall incidence of lead failure was 1.2 vs. 0.3 per 100 lead-years, for high- and low-voltage leads, respectively (P = 0.1). One hundred fifty-one patients agreed to undergo fluoroscopy screening; none of the 264 analysed Optim leads were found to have any fluoroscopically visible structural defects after an average of 31 months post-implant.Conclusion: This study represents the first systematic screening of Optim-coated leads in a large unselected cohort of ICD patients. Over a 5-year period few lead failures were observed and normal fluoroscopic appearance was present in all patients.

Europace: 16 Sep 2013; epub ahead of print
Forleo GB, Di Biase L, Panattoni G, Politano A, ... Natale A, Romeo F
Europace: 16 Sep 2013; epub ahead of print | PMID: 24042736
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Abstract

Risk factors for cardiac implantable electronic device infection: a systematic review and meta-analysis.

Polyzos KA, Konstantelias AA, Falagas ME
Infectious complications after cardiac implantable electronic device (CIED) implantation are increasing over time and are associated with substantial mortality and healthcare costs. The aim of this study was to systematically summarize the literature on risk factors for infection after pacemaker, implantable cardioverter-defibrillator, and cardiac resynchronization therapy device implantation. Electronic searches (up to January 2014) were performed in PubMed, Scopus, and Web of Science databases. Sixty studies (21 prospective, 9 case-control, and 30 retrospective cohort studies) met the inclusion criteria. The average device infection rate was 1-1.3%. In the meta-analysis, significant host-related risk factors for infection included diabetes mellitus (odds ratio (OR) [95% confidence interval] = 2.08 [1.62-2.67]), end-stage renal disease (OR = 8.73 [3.42-22.31]), chronic obstructive pulmonary disease (OR = 2.95 [1.78-4.90]), corticosteroid use (OR = 3.44 [1.62-7.32]), history of the previous device infection (OR = 7.84 [1.94-31.60]), renal insufficiency (OR = 3.02 [1.38-6.64]), malignancy (OR = 2.23 [1.26-3.95]), heart failure (OR = 1.65 [1.14-2.39]), pre-procedural fever (OR = 4.27 [1.13-16.12]), anticoagulant drug use (OR = 1.59 [1.01-2.48]), and skin disorders (OR = 2.46 [1.04-5.80]). Regarding procedure-related factors, post-operative haematoma (OR = 8.46 [4.01-17.86]), reintervention for lead dislodgement (OR = 6.37 [2.93-13.82]), device replacement/revision (OR = 1.98 [1.46-2.70]), lack of antibiotic prophylaxis (OR = 0.32 [0.18-0.55]), temporary pacing (OR = 2.31 [1.36-3.92]), inexperienced operator (OR = 2.85 [1.23-6.58]), and procedure duration (weighted mean difference = 9.89 [0.52-19.25]) were all predictors of CIED infection. Among device-related characteristics, abdominal pocket (OR = 4.01 [2.48-6.49]), epicardial leads (OR = 8.09 [3.46-18.92]), positioning of two or more leads (OR = 2.02 [1.11-3.69]), and dual-chamber systems (OR = 1.45 [1.02-2.05]) predisposed to device infection. This systematic review on risk factors for CIED infection may contribute to developing better infection control strategies for high-risk patients and can also help risk assessment in the management of device revisions.

Europace: 29 Apr 2015; 17:767-777
Polyzos KA, Konstantelias AA, Falagas ME
Europace: 29 Apr 2015; 17:767-777 | PMID: 25926473
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Abstract

Late re-conduction sites in the second session after pulmonary vein isolation using adenosine provocation for atrial fibrillation.

Kaitani K, Kurotobi T, Kobori A, Okajima K, ... Nakazawa Y, Nakagawa Y
Intravenous adenosine triphosphate (ATP) administration could reveal dormant conduction (DC) gaps on the ablation line of a pulmonary vein isolation (PVI). We compared the ATP-provoked DC sites in the initial PVI with the PV re-conduction sites in the second session in patients with paroxysmal atrial fibrillation (AF).Methods and results: We conducted a multicenter, observational study from a prospective registry undergoing AF ablation. A total of 110 consecutive drug-refractory paroxysmal AF patients were enroled in this study. Dormant conduction was detected by an ATP provocation of up to 40 mg during a continuous isoproterenol infusion (0.5-2 μg/min). The DC sites at each of the right and left PVs were precisely determined by using double spiral catheters under the guidance of a three-dimensional constructed anatomical mapping system. In the initial session, DC was observed in 35 patients (31.8%, 1.3 gaps/patient), and the sites of the DC were commonly observed in the carina region (43.5%). Atrial fibrillation recurrence was confirmed in 33 patients (30.0%) during follow-up (27.1 months), and a second session was performed in 24 of 33 patients (70.6%). In the second session, the re-conduction sites were also commonly observed in the carina region (59.5%).Conclusion: The carina region was still a dominant re-conduction site even after the elimination of any ATP-provoked DC in the index procedure.

Europace: 15 Oct 2013; epub ahead of print
Kaitani K, Kurotobi T, Kobori A, Okajima K, ... Nakazawa Y, Nakagawa Y
Europace: 15 Oct 2013; epub ahead of print | PMID: 24128812
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Abstract

Remote monitoring of cardiac implantable electronic devices in Europe: results of the European Heart Rhythm Association survey.

Hernández-Madrid A, Lewalter T, Proclemer A, Pison L, ... conducted by the Scientific Initiatives Committee, European Heart Rhythm Association
The aim of this European Heart Rhythm Association survey was to provide an insight into the current use of remote monitoring for cardiac implantable electronic devices in Europe. The following topics were explored: use of remote monitoring, infrastructure and organization, patient selection and benefits. Centres using remote monitoring reported performing face-to-face visits less frequently. In many centres (56.9%), a nurse reviews all the data and forwards them to the responsible physician. The majority of the centres (91.4%) stated that remote monitoring is best used in patients with implantable cardioverter-defibrillators and those live far from the hospital (76.6% top benefit). Supraventricular and ventricular arrhythmias were reported to be the major events detected earlier by remote monitoring. Remote monitoring will have a significant impact on device management.

Europace: 16 Dec 2013; 16:129-32
Hernández-Madrid A, Lewalter T, Proclemer A, Pison L, ... conducted by the Scientific Initiatives Committee, European Heart Rhythm Association
Europace: 16 Dec 2013; 16:129-32 | PMID: 24344325
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Abstract

Syncope associated with documented paroxysmal atrioventricular block reproduced by adenosine 5\' triphosphate injection.

Blanc JJ, Le Dauphin C
We sought to investigate in patients with syncope the relationship between documented paroxysmal atrioventricular block (AVB) of unknown mechanism and AVB induced by adenosine triphosphate (ATP) injection.Methods and results: We selected patients >45 years free of structural heart disease with syncope related to paroxysmal AVB documented by Holter or in-hospital monitoring, but without any trigger suggestive of vasovagal origin and with normal baseline electrocardiogram. Adenosine triphosphate test was performed according to the usual protocol. Nine patients (all females; mean age 66 ± 14.6 years; range: 48-81 years) matching the abovementioned criteria particularly documented spontaneous complete AVB with long ventricular pauses. Their mean QRS duration was 86.6 ± 14.1 ms and the mean PR interval was 161 ± 21.3 ms. In all patients, ATP induced a long ventricular pause related to AVB (mean duration 13.2 s; range from 7 to 56 s). After a mean follow-up duration of 42 ± 36 months, electrocardiogram (ECG) remained unchanged without progression to permanent AVB or appearance of intraventricular conduction disturbances.Conclusion: Some patients, predominantly older females, with \'normal\' heart and ECG, have syncope associated with spontaneous AVB of unknown origin reproduced during the ATP test. They do not develop permanent AVB during follow-up. This unusual behaviour could be interpreted as an abnormal susceptibility to ATP and these patients could be considered to have \'ATP-sensitive AVB\'. In this subgroup of syncope patients ATP test is useful.

Europace: 15 Oct 2013; epub ahead of print
Blanc JJ, Le Dauphin C
Europace: 15 Oct 2013; epub ahead of print | PMID: 24128810
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Abstract

Dual atrioventricular nodal non-re-entrant tachycardia.

Peiker C, Pott C, Eckardt L, Kelm M, ... Willems S, Meyer C
Dual atrioventricular nodal non-re-entrant tachycardia (DAVNNT), also known as \'double fire\', has recently received more attention since it was demonstrated to mimic more common arrhythmias such as atrial premature beats, atrial fibrillation, and ventricular tachycardia. This is important, since mistaken differential diagnoses and the resulting therapeutic decisions have severe consequences for affected patients. DAVNNT is characterized by conduction characteristics of the atrioventricular (AV) node that leads to a double antegrade conduction of one sinoatrial nodal activity via the slow and fast AV nodal pathways. As a result, the most significant hint from an electrocardiogram (ECG) is a P wave followed by two narrow QRS complexes. Although DAVNNT is rather a rare arrhythmia, it now appears to be more common than previously thought. To date, 68 cases including 3 small single-centre observational studies accumulated over the last 5 years have demonstrated the feasibility and safety of radiofrequency catheter ablation for DAVNNT. Catheter ablation treats this arrhythmia effectively by modifying or eliminating slow pathway function. Here, we review the current state of DAVNNT knowledge systematically and address current challenges presented by this \'ECG chameleon from the AV node\'.

Europace: 17 Apr 2015; epub ahead of print
Peiker C, Pott C, Eckardt L, Kelm M, ... Willems S, Meyer C
Europace: 17 Apr 2015; epub ahead of print | PMID: 25888570
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This program is still in alpha version.