Sarah Traullé

Normal pulmonary veins anatomy is associated with better AF-free survival after cryoablation as compared to atypical anatomy with common left pulmonary vein.

Background: Pulmonary vein cryoablation (PVC) is a new approach in the treatment of recurrent atrial fibrillation (AF). Computed tomography (CT) can be used to evaluate the left atrium anatomy and PVs dimensions to facilitate the procedure. In radiofrequency procedures, some anatomic variants such as common left (CLPV) or right (CRPV) PV were reported as factors associated with technical procedure difficulties and potential long‐term complications. We hypothesized that the absence of CLPV as determined by CT would predict better AF‐free survival after PVC.

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

AIMS 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.

Use of implantable loop recorders in patients with Brugada syndrome and suspected risk of ventricular arrhythmia.

AIMS Implantable cardioverter defibrillator (ICD) therapy is recommended in patients with Brugada syndrome (BS) who experienced aborted sudden cardiac death (SCD) or syncope while the risk stratification of ventricular arrhythmias is a difficult step in patients with atypical symptoms. Implantable loop recorder (ILR) use has been proposed to study patients with unexplained recurrent syncopal events, but its usefulness remains to be defined in patients with BS. In this retrospective study we aimed to investigate the effectiveness of ILR as a diagnostic tool in BS patients suspected of low or moderate risk of SCD. METHODS AND RESULTS We gathered data from 11 ILR recipients with supposed risk of ventricular arrhythmia, issue of Amiens registry of 204 patients with BS. We reported clinical events before and after implant, electrocardiogram (ECG) characteristics, ILR findings, and its limitations as well as tried to specify ILR utility in diagnosis approach and its consequent contribution to guide the optimal therapy. Within the 11 patients (8 men, 3 women), 9 were symptomatic, and 5 had a spontaneous Type 1 ECG pattern. During mean follow-up period of 33 months, 8 patients had a recurrence of symptoms with a mean delay of 9 months after implant. Bradycardia (two atrioventricular blocks and two sinus bradycardia) was detected in four out of eight patients (50%), and there was no ventricular arrhythmia in any patient during symptomatic events which included six vasovagal syncopes and two epileptic seizures. Two initially asymptomatic patients did not experience any symptoms after ILR implant and their ILR recordings did not reveal any arrhythmias. CONCLUSION The ILR contributed to the exclusion of a ventricular arrhythmia as a mechanism of an atypical syncope in patients with electrocardiographic BS and the suspension of the ICD implant. Episodes of transient symptomatic bradycardia were the most common findings suggesting the vagal mechanism of symptoms. The use of ILR should be considered in selected patients with atypical syncope and spontaneous or transient Type 1 ECG pattern.

Dual balloon size strategy for cryoisolation of the pulmonary veins in patients with atrial fibrillation: Comparison of 23 and 28 mm diameter cryoballoons

BACKGROUND Systematic use of a 28mm balloon has been proposed for pulmonary vein cryoisolation in patients with atrial fibrillation. OBJECTIVE To assess the results of a dual balloon size strategy using a 23 or 28mm cryoballoon catheter for pulmonary vein isolation. METHODS A total of 118 patients (mean age 56 ± 10 years) with paroxysmal (n=85) or persistent atrial fibrillation (n=33) were enrolled. Patients with four pulmonary veins<20mm in diameter were isolated with a 23mm cryoballoon (n=29); patients with one pulmonary vein diameter ≥20mm were isolated with a 28mm cryoballoon (n=89). RESULTS No significant difference in procedural variables was observed between the two groups. AF-free survival, after a mean follow-up of 19.9 ± 5 months, was similar in the two groups (69% vs 62%; p=0.57 and between patients with paroxysmal atrial fibrillation (68% vs 68%; p=0.91) or persistent AF (75% vs 48%; p=0.60). AF duration before the ablation procedure (p=0.005) was an independent predictor of AF recurrence. Phrenic nerve palsy rate was not statistically different in the two groups (4 [14%] vs 9 [10%]; p=0.73). The temperature in the right superior pulmonary vein (p=0.008) was an independent predictor of phrenic nerve palsy. Five patients developed left atrial flutter with the 28mm diameter balloon versus none with the 23mm balloon. CONCLUSIONS A dual balloon size strategy was not associated with a lower AF-free survival or a higher procedure-related complication rate in patients in whom the 23mm balloon was used. Pulmonary vein isolation with a 23mm cryoballoon catheter appears to be an appropriate option in selected patients with small pulmonary vein diameters.

Dual phenotypic transmission in Brugada syndrome.

BACKGROUND Brugada syndrome is a genetic heart disease with autosomal dominant inheritance. Family screening commonly detects one parent responsible for transmission of the disease. AIMS To describe atypical transmission of Brugada syndrome. METHODS Between 2001 and 2007, systematic screening, including an electrocardiogram, ajmaline challenge and DNA sequencing of the SCN5A gene, of the first-degree relatives of 62 probands with Brugada syndrome was performed (Programme Hospitalier de Recherche Clinique). RESULTS In two families, both parents transmitted Brugada syndrome to their offspring. In the first family, the proband presented Brugada electrocardiogram features with ajmaline challenge and carried a new SCN5A mutation (p.V1281F). The mutation was also identified in the mother, who had a type 1 aspect on inferior leads with ajmaline. The probands father presented a typical Brugada electrocardiogram pattern on lead V2 with ajmaline and no SCN5A gene mutation. In the second family, the proband was a boy aged 2.5 years who had been resuscitated from sudden cardiac death. Ajmaline challenge revealed a typical Brugada electrocardiogram pattern in both parents but with no mutation in the genes studied. CONCLUSION Family studies should always be exhaustive and discovery of one parent with Brugada syndrome does not eliminate the need for screening of the other parent.

Prevalence and predictive factors of left atrial tachycardia occurring after second-generation cryoballoon ablation of atrial fibrillation

Assess the prevalence and predictors of left atrial tachycardia (LAT) after cryoballoon ablation of pulmonary veins.

Cardiac resynchronisation therapy device implantation in a patient with persistent left superior vena cava: is it still a challenge?

Address for correspondence: Maciej Kubala, MD, Department of Cardiac Arrhythmias, Amiens University Hospital, Boulevard Laennec, 80054 Amiens Cedex 1, tel: (0033)322087232, e-mail: kubala.maciej@chu-amiens.fr Conflict of interest: none declared Kardiologia Polska Copyright

Partial extravenous course of cardiac pacemaker leads. A major risk during device-assisted extraction

Introduction The intracardiac electronic device implantation rate has been constantly increasing for the last 20 years and is accompanied by an increasing lead extraction rate. Percutaneous extraction of transvenous leads of cardiovascular implantable electronic devices is mandatory in the case of pocket infection and/or system infection, resulting in valvular or lead endocarditis. Lead extraction is also performed in the case of venous thrombosis or stenosis and nonfunctioning leads. When leads have been implanted for more than 1 year, device-assisted extraction may be necessary. Locking stylets and dissection sheaths are common extraction tools.

Visualization of effects of cryoballoon ablation during percutaneous treatment of atrial fibrillation.

MOTS CLÉS Fibrillation atriale ; Ballon cryothérapie ; Isolation veines pulmonaires A 62-year-old man with a history of symptomatic resistant paroxysmal atrial fibrillation (AF) underwent percutaneous pulmonary vein (PV) isolation with a 28 mm diameter cryoballoon catheter (Arctic Front®; Medtronic CryoCath LP, Pointe-Claire, QC, Canada). A 20 mm circular loop mapping catheter with eight evenly spaced electrodes (Achieve®; Medtronic, Minneapolis, MN, USA) was used. This wire is especially designed to combine appropriate positioning of the cryoballoon at the PV antrum and visualization of PV potentials throughout cryoablation (Fig. 1A). The patient was in AF at the beginning of the procedure. Cryoenergy was applied twice, successively, in the right inferior PV, right superior PV, left superior PV and left inferior PV (LIPV). At the start of the second cryoenergy application at the LIPV antrum, potentials were clearly visible on the Achieve catheter. After 151 s, we observed the occurrence of an atriovenous block and conversion to sinus rhythm. Focal activity coming from the PV continued but was confined to the vein (Fig. 2A). The venous activity was abolished 30 s later (Fig. 2B). The PV tachycardia cycle length increased progressively prior to break. The whole application lasted 300 s and a temperature of —57 ◦C was reached (Fig. 1B). As in conventional radiofrequency catheter ablation, monitoring of PV activity during balloon ablation is possible. This may allow diagnosis of the culprit pulmonary vein in the triggering and/or maintenance of AF; it may also show the effect of cryoablation. In this case, we had the opportunity to monitor two effects of the cryoballoon: constitution of atriovenous block then termination of PV focal activity.

182: Routine face-profile fluoroscopic screening may be useful for earlier detection, monitoring and management of externalized conductors in patients implanted with Riata leads

Increased rates of structural abnormalities have been reported in the Riata family of implantable cardioverter-defibrillator (ICD) leads. The reliability of defibrillation leads with insulation damage, or abraded cables that are not immediate cause of failure is unknown. The incidence of these defects can be underestimated due to the absence of abnormal electrical parameters detected by regular ICD interrogation. Little is known about the time lag for emergence of functional abnormalities in such leads. Methods Forty eight patients who received small-caliber leads of the Riata family (models 1570, 1572, 1580, 1582, 7000, 7002) in our institution between May 2002 and March 2008 were systematically called for an additional visit including face-profile thoracic fluoroscopy to ascertain integrity of the leads followed by routinely repeated fluoroscopies at every six-month visits. We assessed the prevalence of insulation defects with externalized cables and their relation with adverse events requiring lead revision. We tried to evaluate the time lag for emergence of their electrical dysfunction. Results Thirty five patients, mean age=64±10 years, with at least 7-month completed fluoroscopy follow-up were included in analysis. After 55-month mean follow-up, 57% of patients completed 2 or more spaced fluoroscopies. Externalized conductors were identified in 7 (20%) patients after a 48-months (12-114) mean delay and in 4 (11%) cases the images were classified as borderline. Three of 7 patients with insulation damage required lead replacement for the reason of clinical adverse events. In two other patients an increase of abrasion was observed on repeated fluoroscopy without changes in electrical parameters. Conclusion Insulation damage with externalized conductors was identified in 20% of patients implanted with Riata leads. Routine fluoroscopic screening allowed earlier detection of these defects and may be useful for their closer monitoring and better management.