Corentin Chaumont

BACKGROUND: Patients with nonischemic cardiomyopathy (NICM) and ventricular tachycardia are at increased risk for adverse HF outcomes, and abnormal left ventricular (LV) substrate identified by endocardial unipolar and bipolar low-voltage areas (LVAs) may aid in risk stratification. This study assessed the association of LV unipolar and bipolar LVAs with end-stage HF outcomes in patients with NICM undergoing ventricular tachycardia ablation. METHODS: Patients with NICM and LV ejection fraction (EF) 2 cm ² ) unipolar LVAs as P =0.002) and LVEF (hazard ratio, 1.04 per 1% decrease [95% CI, 1.00–1.09]; P =0.03) were independently associated with higher end-stage HF risk, while bipolar LVA was not (hazard ratio, 0.98, 1% increase [95% CI, 0.96–1.01]; P =0.25). A 3-point risk score based on the Youden index, unipolar LVA ≥70% (2 points), 35% to 70% (1 point), and LVEF ≤25% (1 point), had 82.1% sensitivity and 77.1% specificity for predicting end-stage HF in scores ≥2. CONCLUSIONS: In patients with NICM undergoing ventricular tachycardia ablation, unipolar LVA and LVEF are independent predictors of end-stage HF outcomes. Integrating these predictors yields a prognostic score to identify patients at the highest risk of end-stage HF outcomes.

BACKGROUND: Pulsed field ablation (PFA) is a novel and rapidly expanding energy for the ablation of atrial fibrillation (AF). The relationships between the characteristics of pulmonary vein (PV) and extra-PV PFA applications, and the type of arrhythmia recurrence or durable lesion observed during redo procedures remain unclear. METHODS: In this substudy of the FRANCE PFA national exhaustive multicentric registry, we collected detailed data on PFA applications delivered during the initial AF ablation procedure. Among patients with arrhythmia recurrence undergoing redo procedures with 3-dimensional mapping (n=145), we analyzed the type of recurrence, rates of durable PV isolation (PVI), and the presence of complete block over the ablation lines. RESULTS: Recurrent arrhythmias comprised AF in 58%, atrial tachycardia in 23%, and typical atrial flutter in 9%. AF was less frequently observed when initial ablation targeted extra-PV areas (45 versus 71%; P =0.01) and when a 35-mm diameter catheter was used for PVI only (50 versus 77%; P =0.01). Complete durable PVI was observed in 42% of patients (69% to 76% for each separate PV), and durable roof/PW and mitral isthmus blocks were observed in 62% and 31% of cases, respectively. The rate of durable PVI increased with the number of PFA applications ( P 12 applications. Similarly, roof/PW block rates increased to 88% with >16 applications ( P 12 PFA applications per PV and >16 for the roof/PW. Long-term durability of mitral isthmus block was poor using the Pentaspline PFA catheter.

La stimulation ventriculaire droite conventionnelle induit une désynchronisation inter et intraventriculaire gauche, majorant le risque d’insuffisance cardiaque au long cours. Les techniques de stimulation permanente du système de conduction, stimulation Hisienne ou stimulation de l’aire de la branche gauche (SABG), visent à préserver une activation ventriculaire physiologique. Nous avons démontré la faisabilité et la sécurité de la stimulation du système de conduction dans des centres débutant leur expérience avec ces techniques. Une enquête menée à l’échelle nationale a permis de confirmer une diminution de l’utilisation de la stimulation Hisienne aux dépens de la SABG. Nous nous sommes intéressés à l’impact électromécanique et avons démontré que la SABG permettait un maintien de la synchronisation inter et intraventriculaire gauche chez les patients ayant des QRS spontanés fins. En cas d’arythmie atriale non contrôlée, la stimulation Hisienne combinée à l’ablation du nœud atrio-ventriculaire (NAV) était faisable et efficace, mais associée à des difficultés techniques. Dans une seconde étude comparant la stimulation Hisienne et la SABG dans cette indication, la SABG était associée à une diminution du taux de reconduction atrio-ventriculaire sans compromettre l’efficacité clinique. La stimulation du système de conduction constitue également une approche intéressante en cas de troubles de la conduction, notamment chez les patients ayant un taux attendu de stimulation ventriculaire élevé : un score a ainsi été développé pour prédire un taux de stimulation ventriculaire ≥ 40% chez les patients implantés d’un stimulateur cardiaque en post-TAVI. Enfin, nous nous sommes intéressés à une indication future potentielle : la régularisation de la cadence ventriculaire chez les patients en fibrillation atriale (FA) permanente atteints d’insuffisance cardiaque à FEVG préservée (IC-FEp). Nous avons développé un paramètre Holter permettant de mesurer l’irrégularité cycle à cycle en FA. Un modèle expérimental de cœur de rat isolé, perfusé et stimulé a été mis en place pour étudier l’impact hémodynamique de l’irrégularité ventriculaire. Enfin, nous avons proposé une étude randomisée visant à comparer traitement médicamenteux versus une stratégie de régularisation ventriculaire par ablation du NAV et stimulation du système de conduction, chez les patients IC-FEp en FA permanente bien contrôlée.

BACKGROUND: Up-titration of guideline-directed medical therapy (GDMT) is known to enhance left ventricular function in heart failure (HF) with reduced ejection fraction. However, data regarding its effect on right ventricular (RV) function remain sparse. We aimed to assess the impact of GDMT up-titration on the RV, especially RV to pulmonary artery coupling, and its prognostic value in these patients. METHODS: All consecutive patients (n=291) with left ventricular ejection fraction P P P P P =0.002). In addition, tricuspid annular plane systolic excursion/systolic pulmonary artery pressure was associated with an incremental prognostic value (C-index improvement, P <0.01), over and above prognostic factors, including left ventricular ejection fraction. CONCLUSIONS: This study highlights the independent and incremental prognostic value of tricuspid annular plane systolic excursion/systolic pulmonary artery pressure in HF with reduced ejection fraction during GDMT up-titration, suggesting to also consider RV to pulmonary artery coupling with echocardiography as a treatment goal.

BACKGROUND: Retrograde ethanolization of the vein of Marshall (VOM) has been identified as an adjunct technique in the treatment of persistent atrial fibrillation (AF) and left atrial tachycardia, as stated in the last consensus statement on ablation of AF. However, there is a lack of high-volume data on the technique. METHODS: Through the collection of data from worldwide centers, we performed this international survey that aims to analyze the safety and procedural characteristics of VOM ethanolization in patients referred for treatment of AF or left atrial tachycardia. RESULTS: We included 5579 patients (66 years; range, 20–93) from 26 centers, who underwent VOM ethanolization between 2008 and 2024 for persistent AF (81%), paroxysmal AF (9%), or left atrial tachycardia (10%) under deep sedation (53%) or general anesthesia (47%). A concomitant mitral isthmus line was attempted in 79% of the cases, achieving mitral isthmus block in 98% of patients. There were 0.92% of periprocedural serious adverse events, including 0.09% of peri-procedural death (5 patients). Three patients developed hemodynamic collapse immediately after VOM ethanolization, causing the death of 1 due to anaphylactic shock. One patient died following surgical drainage of pericardial effusion 3 weeks after the procedure. The 3 other deaths were not directly related to VOM ethanolization. Pericardial effusion was observed in 123 patients (2.2%) at the time of or immediately after the procedure, requiring drainage in 20 patients (0.36%) and later in 32 additional patients (0.57%), including 5 (0.09%) requiring drainage. Pacemaker implantation was required in 2 patients (0.04%), 1 for high-grade atrioventricular block and 1 for sinus node dysfunction. CONCLUSIONS: This international survey shows that VOM ethanolization is predominantly performed in patients with persistent AF. It is associated with rare but potentially life-threatening adverse events. Mitral isthmus line ablation results in a very high rate of block when performed concomitantly.