- Email: [email protected]
Direct visualization of slow pathway conduction disappearance during radiofrequency ablation of atrioventricular nodal reentrant tachycardia
86 in pacemaker implanted patients (% of ventricular pacing > 1%; presence of more than 1 AVB episode). Results A total of 165 consecutive patients who underwent TAVI were prospectively included. Out of the 165 patients included, 157 were sampled: 20 in the high grade persistent AV block, 5 in the persistent bundle branch heart block with HV interval > 70 ms, 13 with HV interval < 70 ms, and 119 in the temporary conduction disturbances group. Amongst the 22 patients implanted with PMK following the protocol, only 1 had conduction recovery. On the other hand there were 14 patients who didn’t benefit from a PMK implant but should have. HV interval in the bundle branch block group has an 88% specificity and a 44% sensibility. None of the pacing indication would have been missed if considered at day 3 instead of day 2, independently of HV measurement. Conclusion From this experimental protocol it appears that an HV based algorithm has a good specificity but a poor sensibility. Conduction disorders are stable at day 3 and allow to decide if pacing is needed. Besides QRS duration, PR interval might be of interest in predicting risk of AV block after TAVI. Disclosure of interest The authors declare that they have no competing interest. https://doi.org/10.1016/j.acvdsp.2018.10.188 300
Analysis of remote monitoring of patients with subcutaneous defibrillator C. Delahaye 1,∗ , Sandro Ninni 1,2 , L. Guedon 2 Université de Lille 2, Faculté de médecine 2 Lille University Hospital, Department of Cardiovascular medicine, Lille, France, Lille, France ∗ Corresponding author. E-mail address: [email protected] (C. Delahaye)
1
Introduction Remote monitoring is associated with a high level of evidence in endovascular ICD recipients. Subcutaneous cardioverter are more and more used but there is no data about remote monitoring for these devices. The aim of this study is to provide a qualitative and quantitative analysis of transmissions received by remote monitoring follow-up on a cohort of patients with subcutaneous ICD versus a control cohort of patients with endovascular ICD, and to evaluate the clinical relevance of these transmissions. Method From September 2015 to January 2017, we prospectively and consecutively enrolled all patients undergoing a subcutaneous or endovascular ICD implantation. All transmissions from remote follow-up and reactions to these transmissions were collected. The relevance of alerts was evaluated by a ratio: number of alerts per patient/number of alerts leading to a reaction or intervention. Results A total of 146 patients were included: 69 in the subcutaneous DAI group (44,6 ± 15.6 years old; 25% ischemic cardiopathy), 77 in the endovascular ICD group (64,8 ± 13.9 years old; 77% ischemic cardiopathy) with a mean follow-up of 493 ± 129.6 days. A total of 2393 transmissions were collected including 988 in the endovascular group (41%) and 1405 in the S-ICD group (59%). Twentynine internal electrical shocks were collected: 10 in the intravenous ICD cohort and 9 in the subcutaneous ICD patients. The clinical relevance of these transmissions was lower in the subcutaneous group with only 2% of transmissions leading to a medical intervention compared to 14% in the endovascular group (P < 10—3). The ratio: total alert per patient/relevant alert per patient was 3.2% ± 1.1 in the subcutaneous DAI group and 16% ± 4.7 in the endovascular group (P = 0.0391). Conclusion Remote monitoring of patients with subcutaneous ICD is associated with a higher burden of transmissions with a lower clinical impact compared to patients with endovascular ICDs.
Abstracts Disclosure of interest peting interest.
The authors declare that they have no com-
https://doi.org/10.1016/j.acvdsp.2018.10.189 033
Evolution of conduction disturbances induced by transcatheter aortic valve implantation, and implication in their management M. Echivard 1,∗ , A. Olivier 1 , A. Luc 2 , H. Blangy 1 , L. Freysz 1 , T. Folliguet 3 , P. Maureira 3 , N. Sadoul 1 1 Cardiologie, Vandœuvre-lès-Nancy 2 Unité de Méthodologie, Datamanagement et Statistiques 3 Chirurgie cardiaque, CHU Nancy, Vandoeuvre-lès-Nancy, France ∗ Corresponding author. E-mail address: [email protected] (M. Echivard) Background Managing conduction disturbances after transcatheter aortic valve implantation (TAVI) remains challenging. Predicting factors of permanent pacemaker (PPM) implantation have been studied but there are scarce data about the type and the long term TAVI induced conduction disturbances. Purpose This work aimed to specifically assess each conduction disturbance after TAVI, their incidence and evolution, to improve their management in indication and delay of PPM implantation. Methods This retrospective study included all patients undergoing TAVI at Nancy University Hospital from 2009 to 2016. Patients were followed over 1 year after procedure, with an electrocardiographic control at 3 and 12 months and a device control when implanted with a PPM. Results A total of 505 TAVI procedures were realized, with a 16.2% PPM implantation rate. Left bundle branch block occurrence (26.9%) seems insufficient to implant a PPM early (at 3 months 53.4% had disappeared, there was no PPM dependency and low ventricular pacing rates; non-implanted patients had good outcomes at 1 year) and should only extend duration of monitoring (34.1% developed a high-degree block, during the first 7 days). Per-procedural high-degree atrioventricular (AV) block should lead to an early PPM implantation when persisting after the procedure day (PPM controls confirmed high ventricular pacing rates), but lead to a conservative approach otherwise (10.3% risk of recurrence during hospitalization, no risk after discharge). Post-procedural transient complete AV block is associated with good outcomes since only 7.1% were PPMdependent at 3 months and 30.8% had a ventricular pacing rate < 1%; a conservative approach would need further investigations. Conclusion Specific situations of conduction disturbance lead to different prognosis and should be managed specifically. After 3 months most of patients implanted with PPM have recovered a spontaneous AV conduction, with a low ventricular pacing rate. Disclosure of interest The authors declare that they have no competing interest. https://doi.org/10.1016/j.acvdsp.2018.10.190 053
Direct visualization of slow pathway conduction disappearance during radiofrequency ablation of atrioventricular nodal reentrant tachycardia S. Bun ∗ , A.M. Wedn , D.G. Latcu , K. Hasni , F.A. Benaich , B. Enache , N. Saoudi Cardiologie, Centre Hospitalier Princesse-Grace, Monaco, Monaco ∗ Corresponding author. E-mail address: [email protected] (S. Bun)
05 — Rhythmology and stimulation Background Radiofrequency (RF) ablation of the atrioventricular nodal (AVN) slow pathway (SP) is usually performed during RF delivery in sinus rhythm (SR) while monitoring, as an accepted surrogate of lesion creation, the occurrence of a slow junctional rhythm. This technique is still associated with a low but residual risk of permanent complete AV block (0,5—1%). Purpose To describe a new method for direct visualization of SP conduction suppression during RF delivery by assessing the Atrial-His (AH) interval shortening using high atrial rate pacing. Methods Consecutive patients (pts) admitted for AVN re-rentrant tachycardia (AVNRT) ablation were included. Atrial pacing at a rate inducing constant antegrade SP conduction from the proximal coronary sinus (CS) was performed during RF delivery (remote magnetic navigation catheter), while monitoring the AH interval on the hissian catheter. The SP potential was identified using conventional electroanatomical methods. Results Four pts were included (all men, 59 ± 9 y). Typical AVNRT was induced in all (cycle length 328 ± 52 ms). During ablation, CS pacing was performed at 405 ± 80 ms. A 30 ms AH shortening was observed during the successful RF application in 1 pt (Fig. 1). In 3 pts, a transition from 3:2 Wenckebach (maximal AH 240 ± 100 ms) periods to a 1:1 conduction (AH 160 ± 15 ms) was seen during the successful pulse. A 13 ± 5% of AH interval shortening was measured between baseline AH in SR (86 ± 17 ms) and at the end of the procedure (64 ± 15 ms). All pts were successfully ablated with complete absence of inducibility, jump nor echo beat after SP ablation, after isoproterenol infusion. After a follow-up of 6 months, no recurrences were noticed. Conclusion Fast atrial pacing during RF delivery allows direct visualization of SP conduction disappearance. This new method seems effective and potentially safer than the conventional one.
87 Aim Evaluation of pCS involvement in the circuit of unselected pts with typical AFL. Methods Twenty consecutive pts with typical AFL were included: mean age was 72 ± 12 years, 8 had heart disease, 8 associated atrial fibrillation, and 5 were on amiodarone; left atrial dimension was 21 ± 4 cm2 , right atrial 20 ± 5 cm2 , AFL cycle length (CL) 253 ± 34 ms. A decapolar catheter (5—5 mm) was positioned inside the CS with proximal bipole 1 cm far from Ostium, confirmed by retrograde CS angiography. Results Two groups were compared: pts with pCS within the circuit (GR1, PPI ≤ 20 ms + concealed entrainment) and those without (GR2, PPI > 20 ms). GR1 pts were older: 77,5 ± 4 yrs vs 72 ± 12 yrs; P < 0.05. There was no difference between the two GRs concerning other clinical variables, AFL CL, PII at CTI entry, CTI plateau, and septal CTI. GR1 pts had shorter PPI at pCS (9 ± 3 ms vs 40 ± 15 ms; P < 0.001), and fragmented mesodiastolic pCS APs (106 ± 27 ms vs 58,5 ± 22 ms; P < 0.001) with a lower amplitude (0,98 ± 7 ms vs 1,9 ± 1 ms; P = 0.07). A mid-septal unexcitable scar was found in 5/8 GR1 vs. 1/12 GR2 pts (P < 0,05). All pts were successfully ablated at CTI. A GR1 pt had AFL recurrence and underwent a second attempt: PPI was 60 ms at CTI entry, and ≤ 20 ms at septal CTI and pCS. SeptalCTI RF ablation was ineffective, and AFL was terminated 1 cm inside CS, applying RF at a fragmented AP. Conclusion pCS appears involved in a substantial subset of pts with typical AFL, in which advanced age, low voltage fragmented pCS APs, and presence of a mid-septal scar are prevalent. pCS might be considered as an un ‘‘innocent by-stander’’, but able, in rare cases, to generate a second AFL circuit. Disclosure of interest The authors declare that they have no competing interest. https://doi.org/10.1016/j.acvdsp.2018.10.192 193
Relationship between left ventricular pre-ejection time and ECG parameters after cardiac resynchronisation therapy
Figure 1 AH shortening during RF ablation of the slow pathway with fast atrial pacing. Disclosure of interest peting interest.
The authors declare that they have no com-
https://doi.org/10.1016/j.acvdsp.2018.10.191 071
Is proximal coronary sinus involved in the circuit in some cases of ECG ‘‘typical’’ atrial flutter? P. Damiano 1,2 , A. De Sisti 1,2,∗ , M. Andronache 2 , R. Echalier 2 , M. Font 1 1 Rhythmology Unit, Cardiology Departement, CH Aurillac, Aurillac 2 Rhythmology Unit, Cardiology Departement, CHU de Clermont-Ferrand, Clermont-Ferrand, France ∗ Corresponding author. E-mail address: [email protected] (A. De Sisti) Background It is commonly conceived that coronary sinus (CS) participates in the atrial flutter (AFL) circuit, but limited to fibers surrounding its Ostium. Some authors described proximal CS (pCS) involvement in rare cases of typical AFL or recurrent AFL after successful cavo-tricuspid isthmus (CTI) radiofrequency ablation.
A. Mirolo ∗ , G. Viart , A. Savoure , B. Godin , O. Raitiere , H. Eltchaninoff , F. Anselme Cardiologie, CHU de Rouen, Rouen, France ∗ Corresponding author. E-mail address: [email protected] (A. Mirolo) Introduction Left ventricular pre-ejection time (LVPET) is associated with myocardial efficiency. LVPET increases in patients with heart failure and decreases after cardiac resynchronisation therapy (CRT) with variation according to pacing site. Aim The objective of this study was to evaluate the relationship between electrocardiogram (ECG) parameters and LVPET in patients with CRT. Methods It was an observational, prospective, and monocentric study. From May 2017 to October 2017, all patients who underwent CRT with left quadripolar lead in Rouen University Hospital were included. LVPET was evaluated by echocardiography and defined as the time between the beginning of the QRS and the beginning of pulsed doppler signal positioned in left ventricular outflow tract in apical view. The following parameters on 12-leads ECG were assessed: QRS width in V3, sum of QRS amplitude in all lead. Measures were performed during bi-ventricular pacing (at each pacing point of the quadripolar lead: D1, M2, M3, P4), left ventricular pacing, right ventricular pacing, and spontaneous rhythm. Partial correlation test was used. Results Seventeen patients were included. In each patient, LVPET was correlated with QRS width (P = 0.02, R = 0.194) and QRS amplitude (P < 0.001, R = 0.427). The following relationship was observed: the lower is the LVPET, the lower is the QRS amplitude and the narrow is the QRS width. In each patient, mean variation of QRS width
Analysis of remote monitoring of patients with subcutaneous defibrillator C. Delahaye 1,∗ , Sandro Ninni 1,2 , L. Guedon 2 Université de Lille 2, Faculté de médecine 2 Lille University Hospital, Department of Cardiovascular medicine, Lille, France, Lille, France ∗ Corresponding author. E-mail address: [email protected] (C. Delahaye)
1
Introduction Remote monitoring is associated with a high level of evidence in endovascular ICD recipients. Subcutaneous cardioverter are more and more used but there is no data about remote monitoring for these devices. The aim of this study is to provide a qualitative and quantitative analysis of transmissions received by remote monitoring follow-up on a cohort of patients with subcutaneous ICD versus a control cohort of patients with endovascular ICD, and to evaluate the clinical relevance of these transmissions. Method From September 2015 to January 2017, we prospectively and consecutively enrolled all patients undergoing a subcutaneous or endovascular ICD implantation. All transmissions from remote follow-up and reactions to these transmissions were collected. The relevance of alerts was evaluated by a ratio: number of alerts per patient/number of alerts leading to a reaction or intervention. Results A total of 146 patients were included: 69 in the subcutaneous DAI group (44,6 ± 15.6 years old; 25% ischemic cardiopathy), 77 in the endovascular ICD group (64,8 ± 13.9 years old; 77% ischemic cardiopathy) with a mean follow-up of 493 ± 129.6 days. A total of 2393 transmissions were collected including 988 in the endovascular group (41%) and 1405 in the S-ICD group (59%). Twentynine internal electrical shocks were collected: 10 in the intravenous ICD cohort and 9 in the subcutaneous ICD patients. The clinical relevance of these transmissions was lower in the subcutaneous group with only 2% of transmissions leading to a medical intervention compared to 14% in the endovascular group (P < 10—3). The ratio: total alert per patient/relevant alert per patient was 3.2% ± 1.1 in the subcutaneous DAI group and 16% ± 4.7 in the endovascular group (P = 0.0391). Conclusion Remote monitoring of patients with subcutaneous ICD is associated with a higher burden of transmissions with a lower clinical impact compared to patients with endovascular ICDs.
Abstracts Disclosure of interest peting interest.
The authors declare that they have no com-
https://doi.org/10.1016/j.acvdsp.2018.10.189 033
Evolution of conduction disturbances induced by transcatheter aortic valve implantation, and implication in their management M. Echivard 1,∗ , A. Olivier 1 , A. Luc 2 , H. Blangy 1 , L. Freysz 1 , T. Folliguet 3 , P. Maureira 3 , N. Sadoul 1 1 Cardiologie, Vandœuvre-lès-Nancy 2 Unité de Méthodologie, Datamanagement et Statistiques 3 Chirurgie cardiaque, CHU Nancy, Vandoeuvre-lès-Nancy, France ∗ Corresponding author. E-mail address: [email protected] (M. Echivard) Background Managing conduction disturbances after transcatheter aortic valve implantation (TAVI) remains challenging. Predicting factors of permanent pacemaker (PPM) implantation have been studied but there are scarce data about the type and the long term TAVI induced conduction disturbances. Purpose This work aimed to specifically assess each conduction disturbance after TAVI, their incidence and evolution, to improve their management in indication and delay of PPM implantation. Methods This retrospective study included all patients undergoing TAVI at Nancy University Hospital from 2009 to 2016. Patients were followed over 1 year after procedure, with an electrocardiographic control at 3 and 12 months and a device control when implanted with a PPM. Results A total of 505 TAVI procedures were realized, with a 16.2% PPM implantation rate. Left bundle branch block occurrence (26.9%) seems insufficient to implant a PPM early (at 3 months 53.4% had disappeared, there was no PPM dependency and low ventricular pacing rates; non-implanted patients had good outcomes at 1 year) and should only extend duration of monitoring (34.1% developed a high-degree block, during the first 7 days). Per-procedural high-degree atrioventricular (AV) block should lead to an early PPM implantation when persisting after the procedure day (PPM controls confirmed high ventricular pacing rates), but lead to a conservative approach otherwise (10.3% risk of recurrence during hospitalization, no risk after discharge). Post-procedural transient complete AV block is associated with good outcomes since only 7.1% were PPMdependent at 3 months and 30.8% had a ventricular pacing rate < 1%; a conservative approach would need further investigations. Conclusion Specific situations of conduction disturbance lead to different prognosis and should be managed specifically. After 3 months most of patients implanted with PPM have recovered a spontaneous AV conduction, with a low ventricular pacing rate. Disclosure of interest The authors declare that they have no competing interest. https://doi.org/10.1016/j.acvdsp.2018.10.190 053
Direct visualization of slow pathway conduction disappearance during radiofrequency ablation of atrioventricular nodal reentrant tachycardia S. Bun ∗ , A.M. Wedn , D.G. Latcu , K. Hasni , F.A. Benaich , B. Enache , N. Saoudi Cardiologie, Centre Hospitalier Princesse-Grace, Monaco, Monaco ∗ Corresponding author. E-mail address: [email protected] (S. Bun)
05 — Rhythmology and stimulation Background Radiofrequency (RF) ablation of the atrioventricular nodal (AVN) slow pathway (SP) is usually performed during RF delivery in sinus rhythm (SR) while monitoring, as an accepted surrogate of lesion creation, the occurrence of a slow junctional rhythm. This technique is still associated with a low but residual risk of permanent complete AV block (0,5—1%). Purpose To describe a new method for direct visualization of SP conduction suppression during RF delivery by assessing the Atrial-His (AH) interval shortening using high atrial rate pacing. Methods Consecutive patients (pts) admitted for AVN re-rentrant tachycardia (AVNRT) ablation were included. Atrial pacing at a rate inducing constant antegrade SP conduction from the proximal coronary sinus (CS) was performed during RF delivery (remote magnetic navigation catheter), while monitoring the AH interval on the hissian catheter. The SP potential was identified using conventional electroanatomical methods. Results Four pts were included (all men, 59 ± 9 y). Typical AVNRT was induced in all (cycle length 328 ± 52 ms). During ablation, CS pacing was performed at 405 ± 80 ms. A 30 ms AH shortening was observed during the successful RF application in 1 pt (Fig. 1). In 3 pts, a transition from 3:2 Wenckebach (maximal AH 240 ± 100 ms) periods to a 1:1 conduction (AH 160 ± 15 ms) was seen during the successful pulse. A 13 ± 5% of AH interval shortening was measured between baseline AH in SR (86 ± 17 ms) and at the end of the procedure (64 ± 15 ms). All pts were successfully ablated with complete absence of inducibility, jump nor echo beat after SP ablation, after isoproterenol infusion. After a follow-up of 6 months, no recurrences were noticed. Conclusion Fast atrial pacing during RF delivery allows direct visualization of SP conduction disappearance. This new method seems effective and potentially safer than the conventional one.
87 Aim Evaluation of pCS involvement in the circuit of unselected pts with typical AFL. Methods Twenty consecutive pts with typical AFL were included: mean age was 72 ± 12 years, 8 had heart disease, 8 associated atrial fibrillation, and 5 were on amiodarone; left atrial dimension was 21 ± 4 cm2 , right atrial 20 ± 5 cm2 , AFL cycle length (CL) 253 ± 34 ms. A decapolar catheter (5—5 mm) was positioned inside the CS with proximal bipole 1 cm far from Ostium, confirmed by retrograde CS angiography. Results Two groups were compared: pts with pCS within the circuit (GR1, PPI ≤ 20 ms + concealed entrainment) and those without (GR2, PPI > 20 ms). GR1 pts were older: 77,5 ± 4 yrs vs 72 ± 12 yrs; P < 0.05. There was no difference between the two GRs concerning other clinical variables, AFL CL, PII at CTI entry, CTI plateau, and septal CTI. GR1 pts had shorter PPI at pCS (9 ± 3 ms vs 40 ± 15 ms; P < 0.001), and fragmented mesodiastolic pCS APs (106 ± 27 ms vs 58,5 ± 22 ms; P < 0.001) with a lower amplitude (0,98 ± 7 ms vs 1,9 ± 1 ms; P = 0.07). A mid-septal unexcitable scar was found in 5/8 GR1 vs. 1/12 GR2 pts (P < 0,05). All pts were successfully ablated at CTI. A GR1 pt had AFL recurrence and underwent a second attempt: PPI was 60 ms at CTI entry, and ≤ 20 ms at septal CTI and pCS. SeptalCTI RF ablation was ineffective, and AFL was terminated 1 cm inside CS, applying RF at a fragmented AP. Conclusion pCS appears involved in a substantial subset of pts with typical AFL, in which advanced age, low voltage fragmented pCS APs, and presence of a mid-septal scar are prevalent. pCS might be considered as an un ‘‘innocent by-stander’’, but able, in rare cases, to generate a second AFL circuit. Disclosure of interest The authors declare that they have no competing interest. https://doi.org/10.1016/j.acvdsp.2018.10.192 193
Relationship between left ventricular pre-ejection time and ECG parameters after cardiac resynchronisation therapy
Figure 1 AH shortening during RF ablation of the slow pathway with fast atrial pacing. Disclosure of interest peting interest.
The authors declare that they have no com-
https://doi.org/10.1016/j.acvdsp.2018.10.191 071
Is proximal coronary sinus involved in the circuit in some cases of ECG ‘‘typical’’ atrial flutter? P. Damiano 1,2 , A. De Sisti 1,2,∗ , M. Andronache 2 , R. Echalier 2 , M. Font 1 1 Rhythmology Unit, Cardiology Departement, CH Aurillac, Aurillac 2 Rhythmology Unit, Cardiology Departement, CHU de Clermont-Ferrand, Clermont-Ferrand, France ∗ Corresponding author. E-mail address: [email protected] (A. De Sisti) Background It is commonly conceived that coronary sinus (CS) participates in the atrial flutter (AFL) circuit, but limited to fibers surrounding its Ostium. Some authors described proximal CS (pCS) involvement in rare cases of typical AFL or recurrent AFL after successful cavo-tricuspid isthmus (CTI) radiofrequency ablation.
A. Mirolo ∗ , G. Viart , A. Savoure , B. Godin , O. Raitiere , H. Eltchaninoff , F. Anselme Cardiologie, CHU de Rouen, Rouen, France ∗ Corresponding author. E-mail address: [email protected] (A. Mirolo) Introduction Left ventricular pre-ejection time (LVPET) is associated with myocardial efficiency. LVPET increases in patients with heart failure and decreases after cardiac resynchronisation therapy (CRT) with variation according to pacing site. Aim The objective of this study was to evaluate the relationship between electrocardiogram (ECG) parameters and LVPET in patients with CRT. Methods It was an observational, prospective, and monocentric study. From May 2017 to October 2017, all patients who underwent CRT with left quadripolar lead in Rouen University Hospital were included. LVPET was evaluated by echocardiography and defined as the time between the beginning of the QRS and the beginning of pulsed doppler signal positioned in left ventricular outflow tract in apical view. The following parameters on 12-leads ECG were assessed: QRS width in V3, sum of QRS amplitude in all lead. Measures were performed during bi-ventricular pacing (at each pacing point of the quadripolar lead: D1, M2, M3, P4), left ventricular pacing, right ventricular pacing, and spontaneous rhythm. Partial correlation test was used. Results Seventeen patients were included. In each patient, LVPET was correlated with QRS width (P = 0.02, R = 0.194) and QRS amplitude (P < 0.001, R = 0.427). The following relationship was observed: the lower is the LVPET, the lower is the QRS amplitude and the narrow is the QRS width. In each patient, mean variation of QRS width