Mikael Laredo

Aims: Obesity is associated with atrial fibrillation (AF), atrial remodelling, and cardiometabolic comorbidities. Whether baseline body mass index (BMI) influences procedural safety and effectiveness of pulsed-field ablation (PFA) remains uncertain. We evaluated the association of baseline BMI with procedural characteristics, periprocedural safety, and 1-year arrhythmia recurrence after first-time PFA for AF. Methods and results: FRANCE-PFA is a nationwide registry including consecutive patients undergoing first-time AF ablation with a pentaspline PFA catheter. Patients with available BMI were categorized as <25, 25 to <30, 30 to <35, or ≥35 kg/m2. Periprocedural complications and 1-year atrial arrhythmia recurrence were assessed across BMI categories. Among 5223 patients, BMI was available in 4573 (87.6%). Higher BMI was associated with greater cardiometabolic burden, more persistent AF, larger atria, and more extensive ablation strategies, including fewer pulmonary vein isolation-only procedures and more additional lesion sets (all P < 0.001). Periprocedural complications remained infrequent (1.0%), with no significant difference across BMI categories. At 1 year, recurrence was driven mainly by AF type rather than obesity. Within paroxysmal and non-paroxysmal AF, recurrence rates were comparable between patients with BMI < 35 and ≥35 kg/m2 (13.8% vs. 9.1% and 22.9% vs. 23.3%, respectively; log-rank P = 0.925). Severe obesity was not associated with recurrence after multivariable adjustment (HR, 0.86; 95% CI, 0.65–1.14; P = 0.299), with similar findings when BMI was analysed continuously. Conclusion: In this nationwide PFA cohort, higher BMI identified a more advanced AF phenotype and more extensive ablation strategies but was not independently associated with periprocedural complications or 1-year arrhythmia recurrence.

Background and Aims: Subcutaneous implantable cardioverter defibrillator (S-ICD) therapy is well-established therapy for the prevention of sudden cardiac death. Although general anesthesia (GA) was initially advocated for implantation, non-GA has emerged as a feasible alternative in clinical practice. This study evaluated the early and long-term outcomes associated with anesthetic modality during S-ICD implantation procedures. Methods: The HONEST study nationwide, single-arm, observational cohort included all patients implanted with an S-ICD (EMBLEM™, Boston Scientific) in France between 2012 and 2019. GA was characterized by controlled unconsciousness with airway management, while non-GA included all alternative techniques. Results: Among 4,924 patients, 1,041 (21.1%) underwent non-GA. The proportion of non-GA use increased from 2.5% to 26.9% between 2012 and 2019 (p<0.001). Patients implanted with non-GA modality tended to be older (51 ± 14 vs. 50 ± 15 years), had lower left ventricular ejection fraction (41±16 vs. 43±17%), and fewer secondary prevention indications (33 vs. 38%) (all p0.1). Conclusion: Anesthesia strategy used for S-ICD implantation was not associated with poorer short- or long-term clinical outcomes, supporting non–general anesthesia as a feasible alternative in appropriately selected patients.

Aims: Atrial fibrillation (AF) is highly prevalent among cardiac amyloidosis (CA) patients and contributes significantly to their morbidity and mortality. Evidence regarding AF ablation efficacy and safety in CA patients remains limited. The aim of our study is to evaluate baseline characteristics, clinical course and outcomes of AF ablation in a series of patients with transthyretin (ATTR) or light-chain (AL) CA from a multicentre international registry. Methods and results: Patients with CA who underwent AF ablation were included. Co-primary endpoints were: (i) atrial arrhythmia (AA) recurrence; (ii) a composite endpoint of all-cause mortality and heart failure hospitalization (HFH). 109 patients (mean age 72.4 ± 7.4 years, females 17.4%, persistent AF 64.2%, ATTR 78%, AL 22%) were included. Radiofrequency, cryo-balloon and pulsed-field ablation were performed in 67%, 15% and 18% of patients, respectively; 49.5% received pulmonary vein isolation plus additional ablations. Low voltage zones were documented in 34 out of 44 patients undergoing electro-anatomical mapping (77.3%). During a median follow-up of 22.7 months, 63 patients (58.3%) experienced AA recurrence (32.4% persistent AF recurrence), with no significant differences between CA subtypes (ATTR 59.5% vs. AL 54.2%, log-rank P = 0.55). The composite endpoint of HFH and all-cause death occurred in 27 patients (25%). Recurrence of persistent AF was associated with three-fold higher risk (OR 2.9, P = 0.02) of the composite endpoint. Conclusion: CA patients undergoing AF ablation present high prevalence of persistent AF. Freedom from AA after AF ablation is achieved in 42% of patients after a two-year follow-up. Patients with persistent AF recurrence have a three-fold higher risk of HFH and death.

Nouveaux développements techniques et applications cliniques de l'imagerie par résonance magnétique cardiaque et tomodensitométrie pour le diagnostic et la caractérisation de la cardiomyopathie arythmogène: Les cardiomyopathies arythmogènes (CMA) sont une famille de pathologies cardiaques d’origine génétique dont la principale conséquence est le risque d’arythmie ventriculaires pouvant conduire à la mort subite cardiaque. Les CMA présentent une variété de phénotypes constamment en évolution incluant des modifications structurelles cachées nécessitant une évaluation multiparamétrique. L’imagerie par résonance magnétique cardiaque (IRMC) est essentielle à leur évaluation, compte tenu de l'identification croissante des formes de CMA biventriculaires et touchant le ventricule gauche (VG) de manière prédominante. La tomodensitométrie cardiaque (TDMC), bien que moins établie, présente une utilité potentielle comme outil complémentaire ou alternatif. Dans cette thèse, nous avons profité de notre large cohorte de patients porteur d’une CMA pour poursuivre trois objectifs permettant d'étendre les limites de l'imagerie cardiaque pour le diagnostic et la caractérisation fonctionnelle des CMA. Premièrement, nous avons développé et évalué un nouveau paramètre d’IRMC de suivi de textures intégrant les dynamiques longitudinales et radiales du ventricule droit (VD), qui s'est avéré efficace pour distinguer les patients atteint de CMA, en particulier ceux qui manquent de critères structurels majeurs, des sujets sains, impliquant qu'une analyse bidimensionnelle de la dynamique VD est essentielle pour saisir la physiologie complexe des CMA. Deuxièmement, nous avons décrit les caractéristiques à l’IRMC de la CMA liée aux variants pathogéniques dans Desmoplakine (DSP), une entité spécifique associée à un pronostic particulièrement défavorable au sein de la vaste diversité des CMA, et pour la première fois les avons comparées à celles trouvées dans d’autres formes de CMA avec atteinte du VG. Nous avons constaté que la présence d'un rehaussement tardif diffus s'étendant au-delà du VG inferolatéral associée à un rapport de volume VG-VD en fin de systole ≥ 0,8 pourrait être considérée comme indicatrice d'une forte probabilité pré-test génétique de CMA liée à DSP. Troisièmement, à travers une étude multimodalité, nous avons montré qu'il y avait généralement une faible concordance spatiale entre le substrat arythmogène et les anomalies morpho-fonctionnelles ou la graisse VD, à un niveau segmentaire. Ce résultat ouvre la voie à une intégration de données électrophysiologiques dans les critères diagnostics des CMA et suggère que l'imagerie cardiaque en pratique courante ne peut pas exclure de manière fiable la présence d'un substrat arythmogène à un certaine localisation du VD. Des améliorations déterminantes sont actuellement entreprises pour augmenter l'impact et la généralisabilité des trois ensembles de résultats.

Background: Pulsed‐field ablation (PFA) is increasingly used for catheter ablation of atrial fibrillation (AF), but older patients remain underrepresented in clinical trials. This study aimed to compare procedural outcomes and mid‐term effectiveness of PFA in patients aged ≤ 75 and > 75 years. Methods: In this retrospective single‐center cohort, 479 consecutive patients underwent PFA for AF between January 2022 and April 2024. Patients were grouped by age (≤ 75 vs. > 75 years at ablation). Procedural parameters and acute complications were compared. Arrhythmia‐free survival was assessed with Kaplan–Meier analysis after an 8‐weeks blanking period, and predictors of recurrence were evaluated using Cox regressions. Results: Of 479 patients (mean age 65.0 ± 12.1 years; 73.6% males), 104 (21.7%) were > 75 years at ablation. Patients > 75 years had more comorbidities, including hypertension and impaired renal function. Pulmonary vein isolation was achieved in 99.8% of cases. Acute complication rates were similar between groups (7.7% in > 75 vs. 8.5% in ≤ 75, p = 1.00), with low rates of tamponade (1.5%) and stroke (1.3%). Kaplan–Meier analysis showed no difference in arrhythmia‐free survival. At 6 months, freedom from atrial arrhythmia was 81.4% in the > 75 group and 83.8% in the ≤ 75 group ( p = 0.57); corresponding rates at 12 months were 60.1% and 68.6%. Age was not an independent predictor of recurrence. At last follow‐up, 75.7% of patients were off antiarrhythmic drugs. Conclusions: PFA in patients > 75 years is associated with low complication rates and favorable rhythm outcomes, comparable to those in younger patients. These findings support the use of PFA in elderly patients with AF.

BACKGROUND: Inflammatory, myocarditis-like episodes precede and are associated with higher risk of sustained ventricular arrhythmias and heart failure in patients with pathogenic or likely pathogenic desmoplakin (DSP) variants. Whether the recurrence and treatment of myocarditis-like episodes influence the outcomes in this population is unknown. This study aimed to assess the prognostic impact of the recurrence and treatment of myocarditis-like episodes in patients with pathogenic or likely pathogenic DSP variants. METHODS: The study was designed as an observational cohort study using all patients with pathogenic or likely pathogenic DSP variants in the DSP -ERADOS Network ( Desmopakin Specific Effort for a Rare Disease Outcome Study) enrolled at 31 institutions up until April 30, 2024. Survival from ventricular arrhythmia and heart failure end points and recurrent myocarditis-like episodes was evaluated for both first and recurrent documented myocarditis-like episodes and the impact of immunosuppressive treatment on outcomes assessed. RESULTS: A total of 1014 patients with pathogenic or likely pathogenic DSP variants (62.4% female; mean age, 40.4±17.4 years; 47.1% probands) were included. Among them, 177 individuals (17.5%) experienced ≥1 documented myocarditis-like episode, with 63 of them (35.6%) receiving immunosuppressive treatment. Immunosuppressive treatment of the first documented myocarditis-like episode was associated with reduced risk of ventricular arrhythmia and heart failure outcomes (hazard ratio, 0.18 [95% CI, 0.07–0.45]; P P =0.001, respectively) over a median follow-up of 6.4 years (95% CI, 4.0–10.5). This risk was comparable to that of patients with no history of myocarditis-like episode but did not correlate with a reduction in recurrent episodes after completion of initial immunosuppression (hazard ratio, 0.85 [95% CI, 0.47–1.54]; P =0.599). In contrast, nonsteroidal anti-inflammatory drugs or colchicine treatment did not influence outcomes. CONCLUSIONS: Immunosuppressive treatment of myocarditis-like episodes in DSP patients was associated with improved combined ventricular arrhythmia or heart failure outcomes, supporting future prospective evaluation in DSP cohorts.