Severe Periprocedural Complications After Ablation for Atrial Fibrillation: An International Collaborative Individual Patient Data Registry.

BACKGROUND Catheter ablation for atrial fibrillation (AF) including pulmonary vein isolation and possibly further substrate ablation is the most common electrophysiological procedure. Severe complications are uncommon, but their detailed assessment in a large worldwide cohort is lacking. OBJECTIVES The aim of this study was to determine the incidence of periprocedural severe complications and to provide a detailed characterization of the diagnostic evaluation and management of these complications in patients undergoing AF ablation. METHODS Individual patient data were collected from 23 centers worldwide. Limited data were collected for all patients who underwent catheter ablation, and an expanded series of data points were collected for patients who experienced severe complications during periprocedural follow-up. Incidence, predictors, patient characteristics, management details, and overall outcomes of patients who experienced ablation-related complications were investigated. RESULTS Data were collected from 23 participating centers at which 33,879 procedures were performed (median age 63 years, 30% women, 71% radiofrequency ablations). The incidence of severe complications (n = 271) was low (tamponade 6.8‰, stroke 0.97‰, cardiac arrest 0.41‰, esophageal fistula 0.21‰, and death 0.21‰). Age, female sex, a dilated left atrium, procedure duration, and the use of radiofrequency energy were independently associated with the composite endpoint of all severe complications. Among patients experiencing tamponade, 13% required cardiac surgery. Ninety-three percent of patients with complications were discharged directly home after a median length of stay of 5 days (Q1-Q3: 3-7 days). CONCLUSIONS This large worldwide collaborative study highlighted that tamponade, stroke, cardiac arrest, esophageal fistula, and death are rare after AF ablation. Older age, female sex, procedure duration, a dilated left atrium, and the use of radiofrequency energy were associated with severe complications in this multinational cohort. One in 8 patients with tamponade required cardiac surgery

A worldwide survey on incidence, management and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: The POTTER-AF study.

AIMS Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management and outcome are sparse. METHODS AND RESULTS This international multicenter registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553,729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed at 214 centers in 35 countries. In 78 centers 138 patients (0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (p<0.0001)) were diagnosed with an oesophageal fistula. Periprocedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8%, and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) (odds ratio 7.463 (2.414, 23.072) p<0.001). CONCLUSIONS Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high

A Primary Prevention Clinical Risk Score Model for Patients With Brugada Syndrome (BRUGADA-RISK).

OBJECTIVES: The goal of this study was to develop a risk score model for patients with Brugada syndrome (BrS). BACKGROUND: Risk stratification in BrS is a significant challenge due to the low event rates and conflicting evidence. METHODS: A multicenter international cohort of patients with BrS and no previous cardiac arrest was used to evaluate the role of 16 proposed clinical or electrocardiogram (ECG) markers in predicting ventricular arrhythmias (VAs)/sudden cardiac death (SCD) during follow-up. Predictive markers were incorporated into a risk score model, and this model was validated by using out-of-sample cross-validation. RESULTS: A total of 1,110 patients with BrS from 16 centers in 8 countries were included (mean age 51.8 ± 13.6 years; 71.8% male). Median follow-up was 5.33 years; 114 patients had VA/SCD (10.3%) with an annual event rate of 1.5%. Of the 16 proposed risk factors, probable arrhythmia-related syncope (hazard ratio [HR]: 3.71; p < 0.001), spontaneous type 1 ECG (HR: 3.80; p < 0.001), early repolarization (HR: 3.42; p < 0.001), and a type 1 Brugada ECG pattern in peripheral leads (HR: 2.33; p < 0.001) were associated with a higher risk of VA/SCD. A risk score model incorporating these factors revealed a sensitivity of 71.2% (95% confidence interval: 61.5% to 84.6%) and a specificity of 80.2% (95% confidence interval: 75.7% to 82.3%) in predicting VA/SCD at 5 years. Calibration plots showed a mean prediction error of 1.2%. The model was effectively validated by using out-of-sample cross-validation according to country. CONCLUSIONS: This multicenter study identified 4 risk factors for VA/SCD in a primary prevention BrS population. A risk score model was generated to quantify risk of VA/SCD in BrS and inform implantable cardioverter-defibrillator prescription

La FA méconnue (intérêt d'un questionnaire basé sur les symptomes dans le dépistage de la fibrillation atriale méconnue à haut risque)

Le dépistage systématique de la fibriIIation atriale (FA) par prise du pouls des sujets de plus de 65 ans est recommandé depuis 2012 (ESC). La FA méconnue est responsable d'environ 20% des accidents vasculaires cérébraux (AVC). Si elle peut être silencieuse, détectée par la prise du pouls ou par d'autres techniques, la FA peut être mécounue car les signes cliniques n'y sont pas attribués. Objectif: Le dépistage d'une FA chez les patients de plus de 65 ans consultant en médecine générale. Méthodes: Pendant une semaine tous les patients de plus de 65 ans consultant chez un médecin généraliste ont rempli un questionnaire basé sur des symptômes inexpliqués (palpitations, douleur thoracique, malaise, dyspnée). Si un des symptômes était présent une consultation cardiologique était recommandée. Résultats: 457 patients ont été inclus par 41 médecins généralistes (âge moyen: 76,8 ans, sexe masculin: 63%, HTA: 60%, diabète: 22.8%, antécédents AVC: 14.1%). Les scores CHADS2 et CHA2DS2.VASC moyens étaient de 1,8+-1,4 et 3.4+-1.6. La FA était connue chez 72 patients (16%) de 81,8 ans d'âge moyen, 67% d'hommes, 78% d'hypertendus, 37,5% de diabétiques et 43% avec antécédent d'AVC. Les scores de CHADS2 et CHA2,DS2.VASC étaient de 3,0+-1,6 et 4,6+-1,8. La FA était silencieuse chez 16/72 patients (22%). La FA était suspectée chez 85 patients (19%), avec soit des palpitations (n=25), malaise (n=28), douleur thoracique (n=14), ou dyspnée (n=33). 8 patients avaient un pouls irrégulier. L'âge moyen des patients était de 76,6 ans, 56% étaient des hommes, 59% hypertendus, 20,8% diabétiques et 17.6% avaient un antécédent d'AVC. Les scores de CHADS2 et CHA2DS2.VASC étaient de 2,0+-1,3 et 3,7+-1,5. Une consultation car diologique était proposée et une FA a été diagnostiquée pour 31 patients (36%). 7% des patients de plus de 65 ans en FA vus en médecine de ville peuvent être dépistés par notre questionnaire. Conclusion: L'utilisation d'un questionnaire adapté basé sur les symptômes semble détecter un nombre significatif de FA chez les patients à haut risque. Une amélioration de la prise en charge de la FA peut être attendueMONTPELLIER-BU Médecine UPM (341722108) / SudocMONTPELLIER-BU Médecine (341722104) / SudocSudocFranceF

Late intracardiac orthopedic wire migration presenting as tamponade and stroke:

International audienc

Cryoablation of paroxysmal atrial fibrillation displayed the same results as radiofrequency despite anatomical variants of pulmonary veins

International audienc

Two years after pulmonary vein isolation guided by ablation index—a multicenter study

Background: The use of the Ablation Index (AI) software for paroxysmal atrial fibril-lation (AF) has been associated with higher acute effectiveness and higher 1-year ar -rhythmia freedom. There is, however, a lack of data concerning longer follow-up. We aim to evaluate the 2-year outcomes after a standardized AI- guided pulmonary vein isolation (PVI).Methods: Prospective, multicenter study of consecutive patients referred for parox-ysmal AF ablation from January 2018 to July 2019. PVI was guided by a tailored AI value (≥500 for anterior segment, ≥450 for the roof segments and inferior segments, and 400 for the posterior wall) and an ILD ≤6 mm. The primary endpoints were acute and long-term effectiveness.Results: The study included 218 (842 PV) patients (61% males, median age of 60 [IQR 49– 68] years) with paroxysmal AF. First-pass isolation was obtained in 93% of the pa-tients, with an acute reconnection occurring in 10.6% of the patients (3.2% of the PV) following adenosine trial. After a median follow-up of 26 (IQR 20–30) months, free-dom from any documented atrial arrhythmia was 83.4%, off-AAD. The rate of adverse events was 1.4%. Although procedural parameters differ across centers (p< 0.001), the acute (p= 0.56) and long-term effectiveness (p= 0.83) were consistent between centers.Conclusions: Patients with paroxysmal AF submitted to an AI- guided PVI workflow presented high arrhythmia freedom at 2-years of follow-up

Does Unidirectional Block Exist after a Radiofrequency Line Creation? Insights from Ultra-High-Density Mapping (The UNIBLOCK Study)

Background: Whether unidirectional conduction block (UB) can be observed after creation of a radiofrequency (RF) line is still debated. Previous studies reported a prevalence of 9 to 33% of UB, but the assessment was performed using a point-by-point recording across the line. Ultra-high-density (UHD) system may bring some new insights on the exact prevalence of UB. Purpose: A prospective study was conducted to assess the prevalence of UB and bidirectional block (BB) using UHD system after RF line creation. Methods: Patients referred for atrial RF ablation procedure were included in this multicenter prospective study. UHD maps were performed by pacing both sides of the created line. Results: A total of 80 maps were created in 40 patients (67 ± 12 years, 70% male) by pacing (mean cycle length 600 ± 57 ms) from both sides of the cavotricuspid isthmus line. After a 47 ± 17 min waiting time after the last RF application, UHD maps (mean number of 4842 ± 5010 electrograms, acquired during 6 ± 5 min) showed that BB was unambiguously confirmed on all of them. UB was not observed in any map. After a mean follow-up of 12 ± 4 months, 6 (14%) patients experienced an arrhythmia recurrence. Conclusion: After creation of an RF line, no case of UB was observed using UHD mapping, suggesting that the presence of a conduction block along a RF line is always associated with a block in the opposite direction

Outcomes after cryoballoon or radiofrequency ablation for persistent atrial fibrillation: a multicentric propensity-score matched study

International audiencePURPOSE:Recent data show no benefit of additional ablation beyond pulmonary vein isolation (PVI) in persistent atrial fibrillation (AF). Evidence suggests that radiofrequency energy (RF) and cryoballoon (CRYO) have comparable efficacy for PVI. We aimed to assess the outcomes after a single catheter ablation procedure, comparing PVI using CRYO vs. RF ablation for PVI plus additional ablation in a cohort of patients with persistent AF.METHODS:In this prospective multicenter propensity score-matched comparison, 59 consecutive patients undergoing CRYO ablation of persistent AF were matched to 59 patients treated with RF from November 2010 to June 2012.RESULTS:During a mean follow-up of 15.6 ± 11.5 months, 43.2 % of patients presented atrial arrhythmia relapse after a blanking period of 3 months, which was comparable between the two groups (40.7 % in CRYO vs. 45.8 % in RF, Log rank P = 0.14; HR = 0.67, 95 %CI 0.38-1.16, P = 0.15), despite the fact that 52.5 % of RF patients add additional complex fractionated atrial electrogram ablation, as well as left atrial linear ablation in over two-thirds (roof line in 67.8 % and mitral isthmus in 32.2 %). On multivariate Cox regression, only AF duration in years (HR = 1.10, 95 %CI 1.01-1.10, P = 0.04) was a predictor of relapse. Patients undergoing RF ablation presented a numerically, but non-significantly, lower complication rate (6.8 vs 10.2 %, P = 0.51).CONCLUSION:In our multicenter experience, freedom from atrial arrhythmias was comparable among matched patients treated with CRYO and RF, despite non-significant trends in favor of RF in terms of complications, at the cost of longer procedure times

Ostial vs. wide area circumferential ablation guided by the Ablation Index in paroxysmal atrial fibrillation

Pulmonary vein isolation (PVI) guided by the Ablation Index (AI) has shown high acute and mid-term efficacy in the treatment of paroxysmal atrial fibrillation (AF). Previous data before the AI-era had suggested that wide-area circumferential ablation (WACA) was preferable to ostial ablation. However, with the use of AI, we hypothesize that ostial circumferential ablation is non-inferior to WACA and can improve outcomes in paroxysmal AF. Methods and results Prospective, multicentre, non-randomized, non-inferiority study of consecutive patients were referred for paroxysmal AF ablation from January 2020 to September 2021. All procedures were performed using the AI software, and patients were separated into two different groups: WACA vs. ostial circumferential ablation. Acute reconnection, procedural data, and 1- year arrhythmia recurrence were assessed. During the enrolment period, 162 patients (64% males, mean age of 60 ± 11 years) fulfilled the study inclusion criteria—81 patients [304 pulmonary vein (PV)] in the WACA group and 81 patients (301 PV) in the ostial group. Acute PV reconnection was identified in 7.9% [95% confidence interval (CI), 4.9–11.1%] of PVs in the WACA group compared with 3.3% (95% CI, 1.8–6.1%) of PVs in the ostial group [P < 0.001 for non-inferiority; adjusted odds ratio 0.51 (95% CI, 0.23–0.83), P = 0.05]. Patients in the WACA group had longer ablation (35 vs. 29 min, P = 0.001) and procedure (121 vs. 102 min, P < 0.001) times. No significant difference in arrhythmia recurrence was seen at 1- year of follow-up [11.1% in WACA vs. 9.9% in ostial, hazard ratio 1.13 (95% CI, 0.44–1.94), P = 0.80 for superiority]. Conclusion In paroxysmal AF patients treated with tailored AI-guided PVI, ostial circumferential ablation is not inferior to WACA with regard to acute PV reconnection, while allowing quicker procedures with less ablation time