Sebastien Janin

MEDAFI-Trial (Micro-embolization during ablation of atrial fibrillation): comparison of pulmonary vein isolation using cryoballoon technique vs. radiofrequency energy

AIMS Cerebral embolism is a possible serious complication during catheter ablation of atrial fibrillation (AF). The purpose of this prospective pilot study was to analyse the incidence and possible impact of cryo ablation on cerebral lesions and possible differences to radiofrequency (RF) ablation during pulmonary vein isolation (PVI). METHODS AND RESULTS Pulmonary vein isolation was performed in 89 patients, either with the cryoballoon technique (n = 45) or with RF ablation (n = 44). Phenprocoumon was stopped 3 days before intervention and replaced by subcutaneous low-molecular-weight heparin. During the catheter procedure, an infusion of unfractionated heparin was maintained to achieve an activated clotting time (ACT) of > 300 s. Cerebral magnetic resonance imaging scans were performed 1 day before and after PVI, and at 3-month follow-up. Chronic lesions were observed in 11 patients (12.3%) before PVI without statistically significant difference between the two groups. None of the patients had neurological symptoms during or following the procedure. Seven patients (7.9%) developed acute lesions 1 day after PVI, without statistically significant difference between the group treated by cryoenergy (8.9%) and RF ablation (6.8%). Patients with acute lesions were significantly older compared with those without acute cerebral lesions. No additional cerebral lesions during follow-up were observed. CONCLUSION A considerable portion of patients with AF but without any neurological symptoms had chronic cerebral lesions before PVI. Additional acute lesions could be added after the procedure. Both ablation techniques showed additional cerebral acute lesions with no neurological symptoms after PVI.

Propensity score-matched analysis of effects of clinical characteristics and treatment on gender difference in outcomes after acute myocardial infarction.

The greater mortality observed in women compared to men after acute myocardial infarction remains unexplained. Using an analysis of pairs, matched on a conditional probability of being male (propensity score), we assessed the effect of the baseline characteristics and management on 30-day mortality. Consecutive patients were included from January 2006 to December 2007. Two propensity scores (for being male) were calculated, 1 from the baseline characteristics and 1 from both the baseline characteristics and treatment. Two matched cohorts were composed using 1:1 matching and computed using the best 8 digits of the propensity score. Paired analyses were performed using conditional regression analysis. During the study period, 3,510 patients were included in the registry; 1,119 (32%) were women. Compared to the men, the women were 10 years older, had more co-morbidities, less often underwent angiography and reperfusion, and received less medical treatment. The 30-day mortality rate was 12.3% (130 of 1,060) for the women and 7.2% (167 of 2,324) for the men (p <0.001). The 2 matched populations represented 1,298 and 1,168 patients. After matching using the baseline characteristics, the only difference in treatment was a lower rate of angiography and reperfusion, with a trend toward greater 30-day mortality in women. After matching using both baseline characteristics and treatment, the 30-day mortality was similar for the men and women, suggesting that the increased use of invasive procedures in women could potentially be beneficial. In conclusion, compared to men, the 30-day mortality is greater in women and explained primarily by differences in baseline characteristics and to a lesser degree by differences in management. The difference in the use of invasive procedures persisted after matching by characteristics. In contrast, after matching using the baseline characteristics and treatment, the 30-day mortality was comparable across the genders.

Pulmonary Vein Antrum Isolation and Terminal Part of the P Wave

Background:  Delayed interatrial conduction, manifested on the electrocardiogram as a P wave ≥110 ms (interatrial block, IAB), is highly prevalent and associated with atrial fibrillation (AF). It is correlated with P‐terminal force (Ptf; product of the duration and amplitude of the negative terminal phase of the P wave in lead V1). Our purpose was to describe the modifications of the P‐wave duration and Ptf after pulmonary vein antrum isolation (PVAI) in patients with paroxysmal AF.

Limitaciones de la determinacion de los niveles de los biomarcadores sericos durante el aislamiento de venas pulmonares

INTRODUCTION AND OBJECTIVES Several biomarkers have been used for evaluation and quantification of myocardial injury after effective ablation. We studied possible different thermal stability and usability of the proteins released by cardiac cells injured by different energy sources. METHODS Firstly, we tested in vitro thermal stability of creatinine kinase (CK), myocardial bound creatinine kinase (CKMB), cardiac troponins I (cTnI) and cardiac troponins T (cTnT) in collected blood samples from 15 patients (pts) with confirmed ST-segment elevated myocardial infarction (STEMI). Secondly, the biomarkers were collected and analyzed in 82 pts treated with radiofrequency ablation (RFA) and in 79 pts treated with cryo-balloon ablation (CBA). RESULTS In vitro experiment showed that all biomarkers were stable in low temperature of -30(o)C. Troponins were stable in the high temperatures analyzed. A substantial drop in CK and CKMB levels were measured at 50°C and 40° C, respectively. In vivo study showed that the increase in CKMB levels was highly significant in CBA pts only. Pathological CKMB values were observed in 24% of RFA pts and 98% of CBA pts. Pathological cTnI values were observed in all pts and the rise in cTnI levels was highly significant in both groups after ablation. CONCLUSIONS Both in vitro and in vivo results show that CKMB cannot be used for quantitative determination of myocardial injury produced by radiofrequency energy. Only cardiac troponins reflect myocardial injury, regardless of energy source, and may be considered in future studies for comparison of biomarkers effects of cryo versus radiofrequency ablation.

Recording of quality indicators in the management of acute coronary syndromes: Predictors of reperfusion times

Background: There is wide variation in recording of reperfusion times in the management of ST segment elevation acute coronary syndromes (ACS). We investigated factors that could predict time to reperfusion. Methods: Single-centre, retrospective study of all consecutive patients admitted for primary PCI from June 2009 to October 2010. Door-to-artery (D2A) and Door-to-balloon (D2B) times were calculated from times noted by cathlab. nurses and compared with times from digital recordings of PCI procedures. Predictors of time to reperfusion were identified by logistic regression. Results: 300 patients were included. Median (interquartile range) D2B time recorded by cathlab. nurses (D2B-CN) was 35.5 (24; 52) minutes, 32 (20; 51) min from PCI recordings (D2B-PCI). Average difference between D2B-CN and D2B-PCI was 6.2 min (P < 0.0001). Concordance of percent patients with a D2B time < 90 and < 45 min was mediocre, kappa coefficients 0.44 (95% CI: 0.10–0.79) and 0.68 (95% CI: 0.57–0.80) respectively. By multivariate analysis, older patients had longest D2A times (P = 0.04); patients with longest D2A and D2B times more frequently had elevated creatinine (P = 0.002 (D2A), P = 0.0003 (D2B). Organizational aspects did not influence reperfusion times. Conclusion: Data regarding reperfusion times are unreliable when recorded by nurses. Age and creatinine levels are significantly associated with reperfusion times, whereas organizational aspects are not.

CAN THE “BLEEDING ACADEMIC RESEARCH CONSORTIUM” (BARC) CLASSIFICATION BE APPLIED TO PULMONARY EMBOLISM?

Study Aim: To investigate whether the BARC classification of bleeding events is applicable in the context of PE, where no standard definition exists Anticoagulant and thrombolytic agents form the cornerstone of PE management, but their use is associated with an increased risk of bleeding. Bleeding complications are associated with an increased risk of subsequent adverse outcomes in pulmonary embolism (PE). The “Bleeding Academic Research Consortium” (BARC) developed a classification of bleeding events combining laboratory and clinical parameters, but this classification was developed in ACS patients, and its applicability to other settings remains unknown.

006: Impact of successful thrombus retrieval during primary percutaneous coronary intervention with thrombus aspiration on the infarct size and microvascular obstruction: Insight from contrast-enhanced mag

Background hromboaspiration (TA) during primary percutaneous intervention (PPCI) is effective in opening the infarct-related artery in patients with ST-segment elevation myocardial infarction (STEMI), leading to better reperfusion and improved outcome. However, the effect of positive macroscopic efficiency of TA remains unknown. We aimed to evaluate the impact of positive thrombus retrieval during PPCI with manual TA on infarct size (IS) and microvascular obstruction (MVO) as assessed by contrast-enhanced magnetic resonance imaging (CE-MRI) in a subset of patients with STEMI. Methods Inclusion criteria were patients aged Results 88patients were enrolled, mean age 55±10years; 43.1% in the positive TA group. Main results are presented in the table. Clinical and procedural characteristics (90-min total ischemic time, ST-segment resolution, post-procedural TIMI flow grade and post-stenting myocardial blush grade, and peak troponin) did not differ significantly between groups. Independent predictors of final IS were: positive TA (OR 0.34, 95%CI 0.03-0.71), MVO (OR 1.75, 95%CI 1.28-0.71) and IS at 5days (OR 2.06, 95%CI 1.87-3.32). Conclusion Positive thrombus retrieval during primary PPCI with manual TA in STEMI reduces MVO and in the acute phase and at 6 months and represents a powerful predictor of final infarct size. Table – Main results Negative TA (N=50) Positive TA (N+38) p MVO (%) 7.6±5.1 3.8±3.1 0.003 IS in the acute phase (%) 28.2±20.8 14.9±8.7 0.004 Final IS at 6 months (%) 22.3±19.3 12.0±8.3 0.002

166: Assessment of doubtful aortic stenosis by measuring simultaneous transaortic pressure: A pilot study with fractional flow reserve guidewire

Background Transthoracic echocardiography (TTE) is the reference technique for evaluating aortic stenosis (AS), but in certain cases, estimation of the average gradient and aortic valve area can be difficult. We aimed to assess the feasibility and utility of measuring simultaneous transaortic pressure using a fractional flow reserve (FFR) guidewire in doubtful aortic stenosis. Method Between January 2009 and December 2011, 57 patients with symptoms possibly related to severe AS that was poorly evaluated by echocardiography underwent right and left heart catheterization for assessment of aortic valve area with the Gorlin & Gorlin formula. Transaortic pressure was obtained by 2 invasive methods, namely conventional pullback method from the left ventricle (LV) towards the aorta (PM) with subsequent computerized superposition of the pressure curves, and (2) simultaneous method using a FFR wire introduced into the LV (SM). Results Reasons for inaccurate assessment by echocardiography were atrial fibrillation (75%) and/or low LV ejection fraction (38%). Results of evaluation of mean aortic valve gradient and aortic valve area are summarized in the table below. Agreement between methods (using the kappa coefficient) for severe aortic stenosis defined by an aortic-valve area Conclusions Simultaneous measurement of trans-aortic pressure using a FFR guidewire is feasible and may be an attractive and accurate method for evaluation of doubtful aortic stenosis. Table . Results SM PM TTE Mean aortic valve gradient, mmHg 30.5±14.4 23.6±9.9 28.8±8.0 p vs PM – 0.0002 p vs TTE 0.241 – – Aortic valve area, cm/m2 0.46±0.2 0.48±0.15 0.49±0.1 p vs PM 0.003 – 0.529 p vs TTE 0.074 – –

Invasive Assessment of Doubtful Aortic Stenosis by Measuring Simultaneous Transaortic Gradient With a Pressure Wire

Two-dimensional transthoracic echocardiography (2D-TTE) is the reference technique for evaluating aortic stenosis (AS) but may be unreliable in some cases. We aimed to assess whether the use of a pressure wire to measure simultaneous transaortic gradient and aortic valve area (AVA) could be helpful in patients in whom initial noninvasive evaluations were considered doubtful for AS. Fifty-seven patients (mean age 76 years; 39 men) underwent cardiac catheterization with single arterial access for assessment of AVA with the Gorlin and Gorlin formula. Transaortic pressure was obtained by 2 invasive methods: (1) conventional pullback method (PM) from the left ventricle toward the aorta and (2) simultaneous method (SM) with transaortic pressure simultaneously recorded with a 0.014-inch pressure wire introduced into the left ventricle and with a diagnostic catheter placed in the ascending aorta. Reasons for inaccurate assessment by 2D-TTE were low flow states (88%) and/or atrial fibrillation (79%). Agreement for severe AS defined by AVA <0.6 cm²/m² between SM and 2D-TTE and between SM and PM was fair, with kappa coefficients of 0.38 (95% confidence interval [CI] 0.14-0.75) and 0.36 (95% CI 0.22-0.7) respectively; agreement was poor between 2D-TTE and PM (kappa: 0.23; 95% CI 0.002-0.36). SM led to a reclassification of the severity of AS in 9 patients (15.8%) compared with 2D-TTE and in 11 patients (19.3%) compared with PM. In conclusion, invasive evaluation of doubtful AS by measuring simultaneous transaortic gradient using a pressure wire may provide an attractive method that can lead to a change in therapeutic strategy in a substantial proportion of patients.

INTERPRETING TROPONIN ELEVATION IN RELATION TO SYMPTOM ONSET IN INTERMEDIATE-RISK PULMONARY EMBOLISM

Troponin elevation in the setting of acute pulmonary embolism (PE) is of small magnitude and short duration and can go unnoticed in pts referred late after symptom onset. Prospective, single-center registry of pts ients with confirmed intermediate-risk PE, defined as at least 1 echocardiographic