Jean-Marc Sellal

Characterization of the Left-Sided Substrate in Arrhythmogenic Right Ventricular Cardiomyopathy

Background—The correlates of left ventricular (LV) substrate in arrhythmogenic right ventricular (RV) cardiomyopathy are largely unknown. Methods and Results—Thirty-two patients with arrhythmogenic RV cardiomyopathy (47±14 years; 6 women) were included. RV and LV dysplasia were defined from multidetector computed tomography and cardiac magnetic resonance imaging. Arrhythmias were characterized as right-sided or left-sided on 12-lead ECG recordings at baseline and during isoproterenol testing. In 14 patients, the imaging substrate was compared with voltage mapping and local abnormal ventricular activity. Imaging abnormalities were found in 32 (100%) and 21 (66%) patients on the RV and LV, respectively, intramyocardial fat on multidetector computed tomography being the most sensitive feature. LV involvement related to none of the Task Force criteria. Right-sided arrhythmias were more frequent than left-sided arrhythmias (P=0.003) although the latter were more frequent in case of LV involvement (P=0.02). The agreement between low voltage and fat on multidetector computed tomography was high on the RV when using either endocardial unipolar or epicardial bipolar data (&kgr;=0.82 and &kgr;=0.78, respectively) but lower on the LV (&kgr;=0.54 for epicardial bipolar). LV local abnormal ventricular activity was found in all patients with LV involvement, and none of the others. The density of local abnormal ventricular activity within fat areas was similar between the RV and LV (P=0.57). Conclusions—LV substrate is frequent in arrhythmogenic RV cardiomyopathy, but poorly identified by current diagnostic strategies. Left-sided arrhythmias are more frequent in case of LV involvement. LV fat hosts the same density of local abnormal ventricular activity as RV fat, but is less efficiently detected by voltage mapping. These results support the need for alternative diagnostic strategies to identify LV dysplasia.

Impact of New Technologies and Approaches for Post–Myocardial Infarction Ventricular Tachycardia Ablation During Long-Term Follow-Up

Background—During the past years, many innovations have been introduced to facilitate catheter ablation of post–myocardial infarction ventricular tachycardia. However, the predictors of outcome after ablation were not thoroughly studied. Methods and Results—From 2009 to 2013, consecutive patients referred for post–myocardial infarction ventricular tachycardia ablation were included. The end point of the procedure was complete elimination of local abnormal ventricular activities (LAVA) and ventricular tachycardia (VT) noninducibility. The predictors of outcome with primary end point of VT recurrence were assessed. A total of 125 patients were included (age: 64±11 years; 7 women) for 142 procedures. The left ventricle was accessed via transseptal, retrograde aortic, and epicardial approaches in 87%, 33%, and 37% of patients, respectively. Three-dimensional electroanatomical mapping system was used in 70%, multipolar catheter in 51%, and real-time image integration in 38% (from magnetic resonance imaging in 39% and multidetector computed tomography in 93%) of patients. Before ablation, VT was inducible in 75%, and endocardial/epicardial LAVA were present in 88%/75%. After ablation, complete LAVA elimination was achieved in 60%, and VT noninducibility in 83%. During a median follow-up of 850 days (interquartile range, 439–1707), VT recurrence was observed in 36%. Multivariable analysis identified 3 independent outcome predictors: the ability to achieve complete LAVA elimination (R2=0.29; P<0.0001; risk ratio=0.52 [0.38–0.70]), the use of real-time image integration (R2=0.21; P=0.0006; risk ratio=0.49 [0.33–0.74]), and the use of multipolar catheters (R2=0.08; P=0.05; risk ratio=0.75 [0.56–1.00]). Conclusions—Achievement of complete LAVA elimination and use of scar integration from imaging and multipolar catheters to focus high-density mapping are independent predictors of VT-free survival after catheter ablation for post–myocardial infarction ventricular tachycardia.

Body Surface Mapping to Guide Atrial Fibrillation Ablation

Atrial fibrillation (AF) is the most common rhythm disorder, and is strongly associated with thromboembolic events and heart failure. Over the past decade, catheter ablation of AF has advanced considerably with progressive improvement in success rates. However, interventional treatment is still challenging, especially for persistent and long-standing persistent AF. Recently, AF analysis using a non-invasive body surface mapping technique has been shown to identify localised reentrant and focal sources, which play an important role in driving and perpetuating AF. Non-invasive mapping-guided ablation has also been reported to be effective for persistent AF. In this review, we describe new clinical insights obtained from non-invasive mapping of persistent AF to guide catheter ablation.

Recurrences of symptoms after AV node re-entrant tachycardia ablation: a clinical arrhythmia risk score to assess putative underlying cause.

PURPOSE OF THE RESEARCH To identify clinical factors associated with the probability for each arrhythmic mechanism causing recurring symptoms after atrioventricular nodal re-entrant tachycardia (AVNRT) ablation. Slow pathway radiofrequency ablation is used to treat AVNRT. After ablation, recurrence of symptoms due to AVNRT or other arrhythmias can occur. RESULTS We studied 835 patients successfully treated with AVNRT ablation. Variables associated with each specific arrhythmia underlying symptom recurrence were studied by logistic regression. During a mean follow-up of 2.2 ± 2 years, 136 (16%) patients had a recurrence of symptoms. Following invasive and non-invasive studies, symptoms were mostly attributed to sinus tachycardia, recurrence of AVNRT and atrial arrhythmias (respectively 4.7%, 5.2% and 6.1%). Older age and history of atrial fibrillation were associated with a markedly increased risk of symptom recurrence due to atrial arrhythmias (OR=15.58, 7.09-35.22, p<0.001) whereas younger age was associated with a higher risk of sinus tachycardia. A simple 3-item clinical score based on age categories and atrial fibrillation history efficiently predicted atrial arrhythmia (C-Index=0.82, 0.75-0.89) and sinus tachycardia (C-Index=0.83, 0.75-0.90). 8.3% of patients with scores=0 had atrial arrhythmias whereas 100% of patients with scores ≥4 had atrial arrhythmias. CONCLUSIONS While recurrence of symptoms after successful AVNRT ablation is relatively frequent (16%), true AVNRT recurrence accounts for only 1/3 of these recurrences. A simple clinical score based on age and history of atrial fibrillation enables efficient risk stratification for symptom recurrence attributable to atrial arrhythmias and inappropriate sinus tachycardia.

A stepwise approach to the management of postinfarct ventricular tachycardia using catheter ablation as the first-line treatment: a single-center experience.

Background—The occurrence of ventricular tachycardia (VT) after myocardial infarction is associated with poorer prognosis. In such patients, implantable cardioverter-defibrillators are recommended. Catheter ablation of VT is currently recommended only as an adjunctive therapy. Whether a successful VT ablation alone might be a viable strategy in some of these patients, however, remains unknown. The aim of the present study was to evaluate this strategy. Methods and Results—Between January 2002 and December 2011, 189 patients with cardiomyopathy underwent 259 VT ablations in our center. Forty-five patients (mean age, 65.2±9.6 years; 91% men) with a history of myocardial infarction and mean left ventricular ejection fraction of 39.7±9.7% matched the study criteria and were included in this analysis. Acute success was obtained in 40 of 45 patients (88.9%). During a follow-up, on the basis of our stepwise algorithm (using acute success, repeat electrophysiological study, and recurrence of VT), 19 of 45 patients (42.2%) underwent implantable cardioverter-defibrillators implantation. During a median follow-up of 4.5 (interquartile range, 2.1–7.0) years, all-cause mortality occurred in 14 of 45 patients (31.1%). Using multivariate Cox regression analysis, age (hazard ratio, 1.13; 95% confidence interval, 1.03–1.22; P=0.007) was the only independent predictor of mortality, whereas implantable cardioverter-defibrillators implantation was not (hazard ratio, 0.54; 95% confidence interval, 0.18–1.64; P=0.28) Conclusions—Our results suggest that a stepwise approach to the management of VT with ablation as a first-line treatment in postinfarct patients presenting with VT might be a reasonable option. Further studies are required to confirm these results.

Multicenter Experience With Catheter Ablation for Ventricular Tachycardia in Lamin A/C Cardiomyopathy

Background— Lamin A/C (LMNA) cardiomyopathy is a genetic disease with a proclivity for ventricular arrhythmias. We describe the multicenter experience with percutaneous catheter ablation of sustained monomorphic ventricular tachycardia (VT) in LMNA cardiomyopathy. Methods and Results— Twenty-five consecutive LMNA mutation patients from 4 centers were included (mean age, 55±9 years; ejection fraction, 34±12%; VT storm in 36%). Complete atrioventricular block was present in 11 patients; 3 patients were on mechanical circulatory support for severe heart failure. A median of 3 VTs were inducible per patient; in 82%, mapping was consistent with origin from scar in the basal left ventricle, particularly the septum, but also basal inferior wall and subaortic mitral continuity. After multiple procedures (median 2/patient; transcoronary alcohol in 6 and surgical cryoablation in 2 patients), acute success (noninducibility of any VT) was achieved in only 25% of patients. Partial success (inducibility of a nonclinical VT only: 50%) and failure (persistent inducibility of clinical VT: 12.5%) was attributed to intramural septal substrate in 13 of 18 patients (72%). Complications occurred in 25% of patients. After a median follow-up of 7 months after the last procedure, 91% experienced ≥1 VT recurrence, 44% received or were awaiting mechanical circulatory support or transplant for end-stage heart failure, and 26% died. Conclusions— Catheter ablation of VT associated with LMNA cardiomyopathy is associated with poor outcomes including high rate of arrhythmia recurrence, progression to end-stage heart failure, and high mortality. Basal septal scar and intramural VT origin makes VT ablation challenging in this population.

Is isoproterenol really required during electrophysiological study in patients with Wolff-Parkinson-White syndrome?

UNLABELLED We have studied the results of electrophysiological study (EPS) in patients with Wolff-Parkinson-White syndrome (WPW) and spontaneous adverse clinical presentation and determined whether isoproterenol added incremental value. METHODS EPS was performed in 63 patients with WPW and adverse clinical presentation at baseline. EPS was repeated after infusion of isoproterenol in 37 patients, including 25 without criteria for a malignant form at baseline. RESULTS Atrioventricular orthodromic tachycardia was induced 44%, antidromic tachycardia in 11%, atrial fibrillation (AF) in 68% at baseline. At baseline EPS, criteria for a malignant form (AF induction and shortest CL <250 ms) were noted in 60%; tachycardia was not inducible in 16%. All the patients met the criteria for a malignant form after isoproterenol. CONCLUSIONS EPS at baseline missed 16% of patients at risk of life-threatening arrhythmias who had no inducible tachyarrhythmia and 40% without classical criteria for malignant form.

Myocardial wall thinning predicts transmural substrate in patients with scar-related ventricular tachycardia

BACKGROUND Scar-related ventricular tachycardia (VT) arises from specific substrate according to etiology. OBJECTIVE The purpose of this study was to evaluate the relationship between wall thinning (WT) on multidetector computed tomography (MDCT) and local abnormal ventricular activity (LAVA) in patients with ischemic cardiomyopathy (ICM), postmyocarditis (PMC), and dilated cardiomyopathy (DCM). METHODS Forty-two patients (40 male, age 58 ± 13 years, 22 ICM, 11 PMC, 9 DCM) underwent MDCT before a combined endo-/epicardial VT ablation procedure. WT (<5 mm) and severe wall thinning (SWT) (<2 mm) area on MDCT were compared to the prevalence of endo-/epicardial LAVA during sinus rhythm. RESULTS WT and SWT were found on MDCT in 36 (86%) and 20 (48%) with 42 ± 37 cm2 and 26 ± 24 cm2, respectively. SWT was frequently detected in ICM (ICM 77% vs PMC 27% vs DCM 0%, P <.001). LAVA were frequently observed on the endocardium in ICM and on the epicardium in PMC. Endo-/epicardial facing LAVA were frequently found within SWT areas (91% in <2 mm, 9% in 2-5 mm, and 0% in >5 mm, P < .001). In SWT areas, the presence of endocardial LAVA in ICM and epicardial LAVA in PMC predicted opposite facing LAVA with sensitivity and specificity of 78% and 48% and 79% and 98%, respectively. SWT predicted epicardial LAVA in ICM and endocardial LAVA in PMC with sensitivity and specificity of 89% and 100%, and 100% and 100%, respectively. CONCLUSION SWT is frequently found in ICM and PMC but is not common in DCM. SWT predicts LAVA on the opposite side of the wall (epicardial in ICM and endocardial in PMC), indicating transmural VT substrate. MDCT is useful for identifying VT substrate and helpful for understanding the mechanisms of the location of VT substrate domain.

Incidence and prognostic significance of spontaneous and inducible antidromic tachycardia

AIMS Orthodromic atrioventricular reentrant tachycardia (ORT) is the most common arrhythmia at electrophysiological study (EPS) in patients with pre-excitation. The purpose of the study was to determine the clinical significance and the electrophysiological characteristics of patients with inducible antidromic tachycardia (ADT). METHODS AND RESULTS Electrophysiological study was performed in 807 patients with a pre-excitation syndrome in control state and after isoproterenol. Antidromic tachycardia was induced in 63 patients (8%). Clinical and electrophysiological data were compared with those of 744 patients without ADT. Patients with and without ADT were similar in term of age (33 ± 18 vs. 34 ± 17), male gender (68 vs. 61%), clinical presentation with spontaneous atrioventricular reentrant tachycardia (AVRT) (35 vs. 42%), atrial fibrillation (AF) (3 vs. 3%), syncope (16 vs. 12%). In patients with induced ADT, asymptomatic patients were less frequent (24 vs. 37%; <0.04), spontaneous ADT and spontaneous malignant form more frequent (8 vs. 0.5%; <0.001) (16 vs. 6%; <0.002). Left lateral accessory pathway (AP) location was more frequent (51 vs. 36%; P < 0.022), septal location less frequent (40 vs. 56%; P < 0.01). And 1/1 conduction through AP was more rapid. Orthodromic AVRT induction was as frequent (55.5 vs. 55%), but AF induction (41 vs. 24%; P < 0.002) and electrophysiological malignant form were more frequent (22 vs. 12%; P < 0.02). The follow-up was similar; four deaths and three spontaneous malignant forms occurred in patients without ADT. When population was divided based on age (<20/≥20 years), the older group was less likely to have criteria for malignant form. CONCLUSION Antidromic tachycardia induction is rare in pre-excitation syndrome and generally is associated with spontaneous or electrophysiological malignant form, but clinical outcome does not differ.

Influence of advancing age on clinical presentation, treatment efficacy and safety, and long-term outcome of pre-excitation syndromes: a retrospective cohort study of 961 patients included over a 25-year period

Objectives There are very little data on pre-excitation syndrome (PS) in the elderly. We investigated the influence of advancing age on clinical presentation, treatment and long-term outcome of PS. Setting Single-centre retrospective study of patient files. Participants In all, 961 patients (72 patients ≥60 years (mean 68.5±6), 889 patients <60 years (mean 30.5±14)) referred for overt pre-excitation and indication for electrophysiological study (EPS) were followed for 5.3±5 years. Usual care included 24 h Holter monitoring, echocardiography and EPS. Patients underwent accessory pathway (AP) ablation if necessary. Primary and secondary outcome measures Occurrence of atrial fibrillation (AF) or procedure-induced adverse event. Results Electrophysiological data and recourse to AP ablation (43% vs 48.5%, p=0.375) did not significantly differ between the groups. Older patients more often had symptomatic forms (81% vs 63%, p=0.003), history of spontaneous AF (8% vs 3%, p=0.01) or adverse presentation (poorly tolerated arrhythmias: 18% vs 7%, p=0.0009). In multivariable analysis, patients ≥60 years had a significantly higher risk of history of AF (OR=4.2, 2.1 to 8.3, p=0.001) and poorly tolerated arrhythmias (OR=3.8, 1.8 to 8.1, p=0.001). Age ≥60 years was associated with an increased major AP ablation complication risk (10% vs 1.9%, p=0.006). During follow-up, occurrence of AF (13.9% vs 3.6%, p<0.001) and incidence of poorly tolerated tachycardia (4.2% vs 0.6%, p=0.001) were more frequent in patients ≥60 years, although frequency of ablation failure or recurrence was similar (20% vs 15.5%, p=0.52). In multivariable analysis, patients ≥60 years had a significantly higher risk of AF (OR=2.9, 1.2 to 6.8, p≤0.01). Conclusions In this retrospective monocentre study, patients ≥60 years referred for PS work up appeared at higher risk of AF and adverse presentation, both prior and after the work up. These results suggest that, in elderly patients, the decision for EPS and AP ablation should be discussed in light of their suspected higher risk of events and ablation complications. However, these findings should be further validated in future prospective multicentre studies.