Sinus rhythm endocardial mapping for channels identification in ischemic ventricular tachycardia using a modified electrophysiological triad

Background

In a previous study it was demonstrated that an electrophysiological triad was able to identify critical isthmus in atrial flutter (AFL) patients. This triad is based in the Carto® electroanatomical mapping (EAM) version 7, which displays a histogram of the local activation times (LAT) of the tachycardia cycle length (TCL), in addition to the activation and voltage maps.

Purpose

This study aimed to prospectively assess the ability of a modified electrophysiological triad to identify and localize the ventricular tachycardia's (VT) channels and entrance zones during sinus rhythm mapping.

Methods

Prospective analysis of a unicentric registry of individuals who underwent ischemic VT ablation with Carto® EAM, all in sinus rhythm. All patients with non-ischemic etiology, lack of high-density EAM or lack of mapping in any of the left ventricle walls or structures were excluded. Areas of late potentials and possible channels of re-entry were compared to a modified electrophysiological triad constituted by: areas of low-voltage (<0.5mV), a site of deep histogram valley (LAT-Valley) with less than 20% density points relative to the highest density zone and a prolonged LAT-Valley duration that included 10% or more of the total activation time mapped. We also assessed the relationship between the pre-valley bar (the LAT histogram bar immediately before the prolonged LAT-Valley) and the channel entrances.

Results

A total of 14 patients (14 men, median age 70 IQR 64–78 years) were included. All patients presented with ischemic VT and 86% had a previous inferior myocardial infarction. The median number of collected points were 1733 (IQR 1363–2729). All sinus rhythm maps presented with at least 1 LAT-Valley in the analysed histograms. All arrhythmias were effectively treated after undergoing radiofrequency in the LAT-Valley location, either by blocking the channel entrances or scar homogenization ablation strategy. Also, the pre-valley bar in the histogram marked all the channel entrances in the scar borders. No patient had relapse after a clinical follow up of over 6 months.

Conclusion

In a prospective analysis, a modified electrophysiological triad was able to identify the scar channels in sinus rhythm in all patients. The pre-valley bar in the histogram disclosed the channel entrances. Further studies are needed to assess the usefulness of this algorithm to simplify catheter ablation and improve clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

The peri-infarct gray zone of myocardial fibrosis is a better predictor of ventricular arrhythmias than dense core fibrosis in patients with previous myocardial infarction

Background

Current sudden cardiac death (SCD) risk stratification relies heavily on left ventricular ejection fraction (LVEF), but markers to refine risk assessment are needed. Dense core fibrosis (DCF) and peri-infarct “gray zone” of myocardial fibrosis (GZF) on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) have been proposed as potential arrhythmogenic substrates. The aim of our study was to determine whether DCF and GZF could predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction.

Methods

We performed a single centre retrospective study enrolling consecutive patients with previous myocardial infarction undergoing CMR before implantable cardioverter-defibrillator (ICD) implantation. Areas of LGE were subdivided into “core” DCF and “peri-infarct” GZF zones based on signal intensity (>5 SD, and 2–5 SD above the mean of reference myocardium, respectively).

The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device.

Results

A total of 88 patients (median age 61 years [IQR 54–73], 84% male, median LVEF 30% [IQR 23–36%], 14% secondary prevention) were included. During a median follow-up of 23 months [IQR 9–38], 13 patients reached the primary endpoint (10 appropriate ICD shock, 2 sustained VT or VF, and 1 sudden arrhythmic death). Patients who attained the primary endpoint had similar DCF (30.4±14.7 g vs. 28.0±15.3 g; P=0.601) but a greater amount of GZF (18.1±9.6 g vs. 11.9±6.7 g; P=0.005). On univariate analysis, GZF was associated with the composite endpoint (HR: 1.09 per gram; 95% CI: 1.02–1.15; P=0.006), whereas DCF was not (HR: 1.01 per gram; 95% CI: 0.98–1.05; P=0.571). After adjustment for LVEF, GZF remained independently associated with the primary endpoint (adjusted HR: 1.06 per gram; 95% CI: 1.01–1.12; P=0.035). Decision tree analysis identified 11.9g of GZF as the best cut-off to predict life-threatening arrhythmic events. The primary endpoint occurred in 11 out of the 35 patients (31.4%) with GZF ≥11.9 g, but in only 2 of the 53 patients (3.8%) with GZF <11.9 g – Figure 1.

Conclusions

The extent of peri-infarct GZF seems to be a better predictor of ventricular arrhythmias than DCF. This parameter may be useful to identify a subgroup of patients with previous myocardial infarction at increased risk of life-threatening arrhythmic events.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

A cardiac magnetic resonance myocardial strain patterns analysis in left bundle branch block

Funding Acknowledgements

Type of funding sources: None.

Introduction

Recently, a classification with four types of septal longitudinal strain patterns was described using a speckle tracking based strain analysis in echocardiography suggesting pathophysiological continuum of LBBB-induced LV remodeling. Little data exist on feature tracking cardiac magnetic resonance (FT-CMR) in LBBB patients, and whether such patterns could be reproduced in CMR is not established yet.

Purpose

In this study, we aimed to: 1) Assess and reproduce the new strain patterns classification by CMR and 2) Evaluate its association with LV remodeling and myocardial scar in a LBBB cohort.

Methods

Single center registry which included LBBB patients with septal flash (SF) referred to CMR to assess the structural cause of LV dysfunction. LBBB was defined according to Strauss criteria as strict LBBB, non-strict LBBB or nonspecific LV conduction delay.

A semi-automated FT-CMR was used to quantify myocardial strain and detect the four septal longitudinal and radial strain patterns, according to the recent classification (LBBB-1 through LBBB-4) – Figure. Extent of SF was visually scored as mild, moderate, or prominent.

Results

A total of 115 patients were included (mean age 66±11 years; 57% men; 38% with ischemic heart disease). Median duration of QRS was 150± 26ms and majority of the patients (n=90, 78%) were classified as strict LBBB.

In longitudinal strain analyses LBBB-1 was observed in 23 (20%), LBBB-2 in 37 (32.1%), LBBB-3 in 25 (21.7%), and LBBB-4 in 30 (26%) patients. Patients at higher LBBB stages (longitudinal or radial pattern) had more prominent septal flash, greater LV volumes, lower LV ejection fraction and lower absolute global longitudinal, circumferential and radial strain values compared with patients in less advanced stages (p < 0.05 for all) - table.

There was no difference between patterns in clinical characteristics, ischemic etiology, QRS duration and time delay between septal and lateral LV wall.

Late gadolinium enhancement (LGE) was found in 63 patients (54.8%), with a septal location in 34 (29.6%) patients, lateral in 4 (3.5%) patients, septal and lateral in 11 (9.6%) patients. Furthermore, no difference was found for LGE presence, distribution or location between the four strain patterns.

Conclusions

Among patients with LBBB, our study found a good association between longitudinal and radial strain patterns with the degree of LV remodeling and LV dysfunction by FT-CMR analysis. Additionally, myocardial fibrosis didn’t seem to interfere with the staged LBBB classification.

Sinus rhythm endocardial mapping for channels identification in ischemic ventricular tachycardia using a modified electrophysiological triad

Funding Acknowledgements

Type of funding sources: None.

Background

In a previous study it was demonstrated that an electrophysiological triad was able to identify critical isthmus in atrial flutter (AFL) patients. This triad is based in the Carto® electroanatomical mapping (EAM) version 7, which displays a histogram of the local activation times (LAT) of the tachycardia cycle length (TCL), in addition to the activation and voltage maps.

Purpose

This study aimed to prospectively assess the ability of a modified electrophysiological triad to identify and localize the ventricular tachycardia’s (VT) channels and entrance zones during sinus rhythm mapping.

Methods

Prospective analysis of a unicentric registry of individuals who underwent ischemic VT ablation with Carto® EAM, all in sinus rhythm. All patients with non-ischemic etiology, lack of high-density EAM or lack of mapping in any of the left ventricle walls or structures were excluded. Areas of late potentials and possible channels of re-entry were compared to a modified electrophysiological triad constituted by: areas of low-voltage (<0.5mV), a site of deep histogram valley (LAT-Valley) with less than 20% density points relative to the highest density zone and a prolonged LAT-Valley duration that included 10% or more of the total activation time mapped. We also assessed the relationship between the pre-valley bar (the LAT histogram bar immediately before the prolonged LAT-Valley) and the channel entrances.

Results

A total of 14 patients (14 men, median age 70 IQR 64-78 years) were included. All patients presented with ischemic VT and 86% had a previous inferior myocardial infarction. The median number of collected points were 1733 (IQR 1363─2729). All sinus rhythm maps presented with at least 1 LAT-Valley in the analysed histograms. All arrhythmias were effectively treated after undergoing radiofrequency in the LAT-Valley location, either by blocking the channel entrances or scar homogenization ablation strategy. Also, the pre-valley bar in the histogram marked all the channel entrances in the scar borders. No patient had relapse after a clinical follow up of over 6 months.

Conclusion

In a prospective analysis, a modified electrophysiological triad was able to identify the scar channels in sinus rhythm in all patients. The pre-valley bar in the histogram disclosed the channel entrances. Further studies are needed to assess the usefulness of this algorithm to simplify catheter ablation and improve clinical outcomes.

Late gadolinium enhancement is a strong predictor of life threatening arrhythmias in patients with non-ischemic dilated cardiomyopathy undergoing ICD implantation for primary prevention of sudden card

Funding Acknowledgements

Type of funding sources: None.

Background

The usefulness of implantable cardioverter defibrillators (ICD) for primary prevention of arrhythmic sudden cardiac death (SCD) in patients with non-ischemic dilated cardiomyopathy (DCM) has been questioned. Efforts to improve risk stratification have included scores such as the ‘MADIT-ICD benefit score’, and the use of late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR).

The purpose of this study was to evaluate the potential usefulness of these two tools to assess the risk of life-threatening arrhythmias in patients with non-ischemic DCM undergoing ICD implantation for primary prevention of SCD.

Methods

We conducted a single-center retrospective study of consecutive patients who underwent contrast-enhanced CMR before ICD implantation for primary prevention of SCD. Patients with ischemic cardiomyopathy were used as reference. Patients with non-dilated cardiomyopathies were excluded.

The arrhythmic component of the MADIT-ICD benefit score (VT/VF score) was calculated for each patient, and considered high if ≥ 7, as recommended.

The primary endpoint was the occurrence of SCD or life-threatening arrhythmias (VF or VT >200 bpm). Follow-up was performed by device interrogation in all patients except those who suffered SCD.

Results

A total of 151 patients (93 ischemic, mean age 62±13 years, 75% male) with mean left ventricular ejection fraction (LVEF) of 27±8% were included. Overall, 72% (n=67) ischemic and 45% (n=26) non-ischemic patients had scores ≥ 7 and were considered high-risk. LGE was present in all patients with ischemic cardiomyopathy, and in 76% (n=44) of patients with non-ischemic DCM.

During a median follow-up of 21 (8-38) months, 21 patients (13.9%, 11 ischemic and 10 non-ischemic) met the primary endpoint.

Overall, the event-free survival of non-ischemic patients was similar to that of ischemic patients (log rank p=0.269) – Fig 1A. In patients with non-ischemic DCM, there were 7 arrhythmic events (26.9%) in those with MADIT-ICD VT/VF scores ≥7, and 3 events (9.4%) in those with scores <7 (log rank p= 0.104) – Fig 1B.

In the same population, there were 10 arrhythmic events (23%) in patients with LGE, but no events in patients without LGE (log rank p=0.036) – Fig 1C.

LVEF was similar in patients with and without arrhythmic events (26±8% vs. 27±7%, p=0.717), and in those with and without LGE (26±7% vs. 28±9%, p=0.342).

Conclusion

The presence of LGE is a strong predictor of life threatening arrhythmias in patients in non-ischemic DCM undergoing ICD implantation for primary prevention, seemingly outperforming the clinical MADIT-ICD benefit score.

The peri-infarct gray zone of myocardial fibrosis is a better predictor of ventricular arrhythmias than dense core fibrosis in patients with previous myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Current sudden cardiac death (SCD) risk stratification relies heavily on left ventricular ejection fraction (LVEF), but markers to refine risk assessment are needed. Dense core fibrosis (DCF) and peri-infarct "gray zone" of myocardial fibrosis (GZF) on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) have been proposed as potential arrhythmogenic substrates. The aim of our study was to determine whether DCF and GZF could predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction.

Methods

We performed a single centre retrospective study enrolling consecutive patients with previous myocardial infarction undergoing CMR before implantable cardioverter-defibrillator (ICD) implantation. Areas of LGE were subdivided into "core" DCF and "peri-infarct" GZF zones based on signal intensity (>5 SD, and 2-5 SD above the mean of reference myocardium, respectively).

The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device.

Results

A total of 88 patients (median age 61 years [IQR 54-73], 84% male, median LVEF 30% [IQR 23-36%], 14% secondary prevention) were included. During a median follow-up of 23 months [IQR 9-38], 13 patients reached the primary endpoint (10 appropriate ICD shock, 2 sustained VT or VF, and 1 sudden arrhythmic death). Patients who attained the primary endpoint had similar DCF (30.4g ± 14.7 vs. 28.0g ± 15.3; P = 0.601) but a greater amount of GZF (18.1g ± 9.6 vs. 11.9g ± 6.7; P = 0.005). On univariate analysis, GZF was associated with the composite endpoint (HR: 1.09 per gram; 95%CI: 1.02-1.15; P = 0.006), whereas DCF was not (HR: 1.01 per gram; 95%CI: 0.98-1.05; P = 0.571). After adjustment for LVEF, GZF remained independently associated with the primary endpoint (adjusted HR: 1.06 per gram; 95% CI: 1.01-1.12; P = 0.035). Decision tree analysis identified 11.9g of GZF as the best cut-off to predict life-threatening arrhythmic events. The primary endpoint occurred in 11 out of the 35 patients (31.4%) with GZF ≥11.9g, but in only 2 of the 53 patients (3.8%) with GZF <11.9g – Figure.

Conclusions

The extent of peri-infarct GZF seems to be a better predictor of ventricular arrhythmias than DCF. This parameter may be useful to identify a subgroup of patients with previous myocardial infarction at increased risk of life-threatening arrhythmic events.

Relationship between electrical activity and left atrial volume during atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pulmonary veins (PV) ostia were previously identified as the left atrium (LA) areas with the shortest refractory period during sinus rhythm. Pulmonary veins isolation (PVI) became standard of care, but clinical results are still suboptimal. Currently, atrial fibrillation (AF) cycle length mapping (CLM) is possible due to a special tool of the Carto® electroanatomical mapping, which identifies areas in the left atria with shortest refractory period, during AF.

Purpose

Using this new EAM feature, our study aimed to assess the relationship between short refractory period LA areas and left atrial volume and AF type, known predictors of AF relapse.

Methods

Retrospective analysis of an unicentric registry of individuals with symptomatic drug-refractory AF who underwent PVI AF ablation with Carto® EAM. CLM was performed. CL maps were created with a high-density mapping Pentaray® catheter before and after PVI. We assessed areas of short cycle length (SCL) (defined as 120 to 250ms), and their relationships with complex fractionated atrial electrograms (CFAE), and low-voltage zones (from 0.1 to 0.3mV).

Results

A total of 35 patients (21 men, median age 62 IQR 53-71 years) were included. Most patients presented with persistent AF (n=23, 66%), and 8 patients (23%) had a previous PVI. The mean shortest measured cycle length in AF was 134ms (SD ± 23ms). There was a negative correlation between LA volume and SCL areas after PVI (Spearman Correlation coefficient [ρ] = - 0.47, P = 0.037). There was no correlation between LA volume and SCL areas before the PVI procedure (ρ = -0.06, P = 0.776), nor between AF type and SCL (ρ = -0.118, P = 0.620). All patients presented areas of SCL located in the PVs or their insertion, 76% in the posterior/roof region adjacent to the left superior pulmonary vein (LSPV) and 76% in the anterior region of the wall adjacent to the right superior pulmonary vein (RSPV). These two areas remained the fastest even after PVI. The anterior mitral region rarely presented SCL (16%). SCL were related to low-voltage areas in 93% and were adjacent to CFAE in 84% of the cases. Low-voltage areas and CFAE were more frequent and had a larger LA dispersion than SCL.

Conclusion

Our study shows that LA volume, not AF type, is correlated with remaining SCL areas after a pulmonary vein isolation procedure. This finding suggests a possible causal link between increased LA volume and AF relapse post-PVI. More studies are needed to assess the role of the SCL areas as a potential ablation target and their impact on AF ablation outcomes.

[Sarcoid Granulomas Over Scars: Beyond Sarcoidosis]

Sarcoid granulomas can be found in a wide range of diseases and differentiating sarcoidosis from a sarcoid-like reaction may be a challenge. We present a woman with erythematoviolaceous papulonodular lesions located on the ears where piercings were placed. A skin biopsy showing an infiltrate of sarcoid and focal tuberculoid granulomas did not exclude sarcoidosis. There was a slight increase in the level of angiotensin-converting enzyme. Systemic involvement due to sarcoidosis was excluded. Epicutaneous tests performed revealed a strong positive reaction to palladium and nickel, supporting the diagnosis of granulomatous contact dermatitis. There are only a few reports of granulomatous contact dermatitis to palladium with piercings as the source of sensitization. The formation of sarcoid granulomas can represent either a sarcoid-like reaction or a form of cutaneous sarcoidosis, and patch tests are essential in order to establish the diagnosis.

Ventricular tachycardia ablation in nonischemic cardiomyopathy

Introduction

Catheter ablation outcomes for drug-resistant ventricular tachycardia (VT) in nonischemic cardiomyopathy (NICM) are suboptimal when compared to ischemic cardiomyopathy. We aimed to analyse the long-term efficacy and safety of percutaneous catheter ablation in this subset of patients.

Methods

Single-center observational retrospective registry including consecutive NICM patients who underwent catheter ablation for drug-resistant VT during a 10-year period. The efficacy endpoint was defined as VT-free survival after catheter ablation, while safety outcomes were defined by 30-days mortality and procedure-related complications. Independent predictors of VT recurrence were assessed by Cox regression.

Results

In a population of 68 patients, most were male (85%), mean left ventricular ejection fraction (LVEF) was 34±12%, and mean age was 58±15 years. All patients had an implantable cardioverter-defibrillator. Twenty-six (38%) patients underwent epicardial ablation (table 1). Over a median follow-up of 3 years (IQR 1–8), 41% (n=31) patients had VT recurrence and 28% died (n=19). Multivariate survival analysis identified LVEF (HR= 0.98; 95% CI 0.92–0.99, p=0.046) and VT storm at presentation (HR=2.38; 95% CI 1.04–5.46, p=0.041) as independent predictors of VT recurrence. The yearly rates of VT recurrence and overall mortality were 21%/year and 10%/year, respectively. No patients died at 30-days post-procedure, and mean hospital length of stay was 5±6 days. The complication rate was 7% (n=5, table 1), mostly in patients undergoing epicardial ablation (4 vs 1 in endocardial ablation, P=0.046).

Conclusion

LVEF and VT storm at presentation were independent predictors of VT recurrence in NICM patients after catheter ablation. While clinical outcomes can be improved with further technical and scientific development, a tailored endocardial/epicardial approach was safe, with low overall number of complications and no 30-days mortality.

Funding Acknowledgement

Type of funding sources: None.

A new electrophysiological triad for atrial flutter critical isthmus identification and localization

Introduction

In a previous retrospective study it was demonstrated that an electrophysiological triad was able to identify critical isthmus in atrial flutter (AFL) patients. This triad is based in the Carto® electroanatomical mapping (EAM) version 7, which displays a histogram of the local activation times (LAT) of the tachycardia cycle length (TCL), in addition to the activation and voltage maps. This study aimed to prospectively assess the ability of an electrophysiological triad to identify and localize the AFL's critical isthmus.

Methods

Prospective analysis of a unicentric registry of individuals who underwent left AFL ablation with Carto® EAM. All patients with non-left AFL, lack of high-density EAM, less than 2000 collected points or lack of mapping in any of the left atrium walls or structures were excluded. Ablation sites of arrhythmia termination were compared to an electrophysiological triad constituted by: areas of low-voltage (0.05 to 0.3mV), sites of deep histogram valleys (LAT-Valleys) with less than 20% density points relative to the highest density zone and a prolonged LAT-Valley duration that included 10% or more of the TCL. The longest LAT-Valley was designated as the primary valley, while additional valleys were named as secondary.

Results

A total of 12 patients (9 men, median age 72 IQR 67–75 years) were included. All patients presented with left AFL and 67% had a previous atrial fibrillation and/or flutter ablation. The median TCL and number collected points were 250 (230–290) milliseconds and 3150 (IQR 2340–3870) points, respectively. All AFL presented with at least 1 LAT-Valley in the analysed histograms, which corresponded to heterogeneous low-voltage areas (0.05 to 0.3mV) and encompassed more than 10% of TCL. Eleven of the 12 patients presented with at least 1 secondary LAT-Valley. All arrhythmias were effectively terminated after undergoing radiofrequency ablation in the primary or the secondary LAT-Valley location.

Conclusion

In a prospective analysis, an electrophysiological triad was able to identify the AFL critical isthmus in all patients. Further studies are needed to assess the usefulness of this algorithm to improve catheter ablation outcomes.

Funding Acknowledgement

Type of funding sources: None.

Electrical anatomy of the left atrium during atrial fibrillation

Introduction

Twenty years ago, pulmonary veins (PV) ostia were identified as the left atrium (LA) areas with the shortest refractory period during sinus rhythm. Pulmonary veins isolation (PVI) became standard of care, but clinical results are still suboptimal. Today, a special tool using the Carto® electroanatomical mapping (EAM) allows for AF cycle length mapping (CLM), to identify the areas in the left atria with shortest refractory period, during atrial fibrillation. Using this EAM tool, our study aimed to find the LA areas with the shortest refractory period to better recognize electrical targets for catheter ablation.

Methods

Retrospective analysis of an unicentric registry of individuals with symptomatic drug-refractory AF who underwent PVI with Carto® EAM. CLM was performed with a high-density mapping Pentaray® catheter before and after PVI and in 4 redo procedures. We assessed areas of short cycle length (SCL) (defined as 120 to 250ms), and their relationships with complex fractionated atrial electrograms (CFAE), and low-voltage zones (from 0.1 to 0.3mV).

Results

A total of 18 patients (8 men, median age 63 IQR 58–71 years) were included. Most patients presented with persistent AF (n=12, 67%), and 4 patients (22%) had a previous PVI. The mean shortest measured cycle length in AF was 140ms (SD ±27ms). All patients presented areas of SCL located in the PVs or their insertion, 70% in the posterior/roof region adjacent to the left superior pulmonary vein (LSPV) (figure 1) and 60% in the anterior region of the right superior pulmonary vein (RSPV). These two areas remained the fastest even after PVI. The anterior mitral region rarely presented SCL (17%). SCL were related to low-voltage areas in 94% and were adjacent to CFAE. Low-voltage areas and CFAE were more frequent and had a larger LA dispersion than SCL.

Conclusion

We confirmed in 3D mapping that PVs are the LA zones with shortest refractory period, not only in sinus rhythm but also during AF. The persistence of SCL areas in the border zones of the PVI lines suggest the benefit of a more extensive CLM guided ablation. Larger studies are needed.

Funding Acknowledgement

Type of funding sources: None. Short cycle length mapping

The gray zone of myocardial fibrosis is a better predictor of ventricular arrhythmias than total myocardial fibrosis in patients with previous myocardial infarction

Background

Current sudden cardiac death (SCD) risk stratification relies heavily on the assessment of left ventricular ejection fraction (LVEF), but markers that could refine risk assessment are needed. Total fibrosis mass (TFM) and “gray zone” of myocardial fibrosis (GZF) on late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) have been proposed as potential arrhythmogenic substrates. The aim of our study was to determine whether TFM and GZF can predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction.

Methods

We performed a single centre retrospective study enrolling all consecutive patients with previous myocardial infarction undergoing LGE-CMR before implantable cardioverter-defibrillator (ICD) implantation for primary or secondary prevention. TFM and GZF were defined as myocardial tissue with signal-intensities >6 SD and 2–6 SD above the mean of reference myocardium, respectively. The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device.

Results

A total of 55 patients (mean age 62±12 years, 87% male, mean LVEF 30% ± 8%) were included. During a mean follow-up period of 34±15 months, 10 patients reached the primary endpoint (8 appropriate ICD shock, 2 sustained VT or VF). Patients who attained the primary endpoint had similar TFM (28.6g ± 14.5 vs. 23.1g ± 14.5; P=0.283) but larger GZF (25.3g ± 11.0 vs 15.6g ± 7.3; P=0.001). After adjustment for LVEF, GZF remained independently associated with the composite arrhythmic endpoint (adjusted hazard ratio [aHR]: 1.10; 95% CI: 1.03–1.17; P=0.005), whereas TFM did not (aHR: 1.02; 95% CI: 0.98–1.06; P=0.394). Decision tree analysis identified 16.4g of GZF as the best cut-off to predict life-threatening arrhythmic events. The primary endpoint occurred in 9 out of the 22 patients (41%) with GZF >16.4g, but in only 1 of the 33 patients (3%) with GZF ≤16.4g – Figure.

Conclusions

The extent of GZF seems to be a better predictor of ventricular arrhythmias than TFM. This LGE-CMR parameter may be useful to identify a subgroup of patients with previous myocardial infarction at an increased risk of life-threatening arrhythmic events.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of subcutaneous implantable cardioverter-defibrillator appropriate and inappropriate shocks

Funding Acknowledgements

Type of funding sources: None.

Background

Previous studies have shown an adverse prognosis for patients with transvenous implantable cardioverter-defibrillators (ICD) who receive both appropriate and inappropriate shocks. There is a paucity of data regarding the prognosis of inappropriate shocks in patients with a subcutaneous ICD (S-ICD).

Purpose

To assess and characterize S-ICD appropriate (AS) and inappropriate shocks (IAS) and their impact on mortality.

Methods

Single center observational registry of 162 consecutive patients who underwent S-ICD implantation for primary and secondary prevention between November 2009 and September 2020. Only follow-up data of at least 6 months was analysed to identify predictors of both IAS and AS and their mortality impact.

Results

A total of 144 patients were included in the analysis. Mean age was 42.2 ± 16.6 years and 75% of the patients were male. One hundred and four patients (72.2%) implanted the S-ICD in primary prevention. The most common etiology was ischemic cardiomyopathy (22.9%) followed by hypertrophic cardiomyopathy (18.8%) and dilated idiopathic cardiomyopathy (14.6%). During a mean follow-up of 42.3 ± 29.9 months a total of 48 patients (33.3%) experienced at least one S-ICD shock. Twenty-nine (20.1%) patients received AS due to VT/VF and 31 patients (21.5%) received IAS. Eighteen (58.1%) of the IAS were due to oversensing/noise/discrimination errors and the remaining due to supraventricular tachycardia. Overall, patients with AS (HR 4.93, 95% CI 1.58-15.36, p = 0.006) and higher number of total AS (HR 1.10, 95% CI 1.00-1.20, p = 0.044) were associated with higher mortality during follow-up. S-ICD IAS therapy did not affect overall mortality (HR 1.71, 95% CI 0.21-14.0, p = 0.616). Conclusions: In patients with S-ICD, those who receive AS, in contrast to IAS, seem to have a worse prognosis. Large scale studies are needed to confirm this hypothesis and to explain this findings. Abstract Figure. Survival curves for AS and IAS

Electrical anatomy of the left atrium during atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Twenty years ago, pulmonary veins (PV) ostia were identified as the left atrium (LA) areas with the shortest refractory period during sinus rhythm. Pulmonary veins isolation (PVI) became standard of care, but clinical results are still suboptimal. Today, a special tool using the Carto® electroanatomical mapping (EAM) allows for AF cycle length mapping (CLM), to identify the areas in the left atria with shortest refractory period, during atrial fibrillation. Using this EAM tool, our study aimed to find the LA areas with the shortest refractory period to better recognize electrical targets for catheter ablation.

Methods

Retrospective analysis of an unicentric registry of individuals with symptomatic drug-refractory AF who underwent PVI with Carto® EAM. CLM was performed with a high-density mapping Pentaray® catheter before and after PVI and in 4 redo procedures. We assessed areas of short cycle length (SCL) (defined as 120 to 250ms), and their relationships with complex fractionated atrial electrograms (CFAE), and low-voltage zones (from 0.1 to 0.3mV).

Results

A total of 18 patients (8 men, median age 63 IQR 58-71 years) were included. Most patients presented with persistent AF (n = 12, 67%), and 4 patients (22%) had a previous PVI. The mean shortest measured cycle length in AF was 140ms (SD ±27ms). All patients presented areas of SCL located in the PVs or their insertion, 70% in the posterior/roof region adjacent to the left superior pulmonary vein (LSPV) (figure 1) and 60% in the anterior region of the right superior pulmonary vein (RSPV). These two areas remained the fastest even after PVI. The anterior mitral region rarely presented SCL (17%). SCL were related to low-voltage areas in 94% and were adjacent to CFAE. Low-voltage areas and CFAE were more frequent and had a larger LA dispersion than SCL.

Conclusion

  We confirmed in 3D mapping that PVs are the LA zones with shortest refractory period, not only in sinus rhythm but also during AF. The persistence of SCL areas in the border zones of the PVI lines suggest the benefit of a more extensive CLM guided ablation. Larger studies are needed. Abstract Figure 1

Ventricular tachycardia ablation in nonischemic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Catheter ablation outcomes for drug-resistant ventricular tachycardia (VT) in nonischemic cardiomyopathy (NICM) are suboptimal when compared to ischemic cardiomyopathy. We aimed to analyse the long-term efficacy and safety of percutaneous catheter ablation in this subset of patients.

METHODS

Single-center observational retrospective registry including consecutive NICM patients who underwent catheter ablation for drug-resistant VT during a 10-year period. The efficacy endpoint was defined as VT-free survival after catheter ablation, while safety outcomes were defined by 30-days mortality and procedure-related complications. Independent predictors of VT recurrence were assessed by Cox regression.

RESULTS

In a population of 68 patients, most were male (85%), mean left ventricular ejection fraction (LVEF) was 34 ± 12%, and mean age was 58 ± 15 years. All patients had an implantable cardioverter-defibrillator. Twenty-six (38%) patients underwent epicardial ablation (table 1). Over a median follow-up of 3 years (IQR 1-8), 41% (n = 31) patients had VT recurrence and 28% died (n = 19). Multivariate survival analysis identified LVEF (HR= 0.98; 95%CI 0.92-0.99, p = 0.046) and VT storm at presentation (HR = 2.38; 95%CI 1.04-5.46, p = 0.041) as independent predictors of VT recurrence. The yearly rates of VT recurrence and overall mortality were 21%/year and 10%/year, respectively. No patients died at 30-days post-procedure, and mean hospital length of stay was 5 ± 6 days. The complication rate was 7% (n = 5, table 1), mostly in patients undergoing epicardial ablation (4 vs 1 in endocardial ablation, P = 0.046).

CONCLUSION

LVEF and VT storm at presentation were independent predictors of VT recurrence in NICM patients after catheter ablation. While clinical outcomes can be improved with further technical and scientific development, a tailored endocardial/epicardial approach was safe, with low overall number of complications and no 30-days mortality. Abstract Figure.

A new electrophysiological triad for atrial flutter critical isthmus identification and localization

Funding Acknowledgements

Type of funding sources: None.

Introduction

In a previous retrospective study it was demonstrated that an electrophysiological triad was able to identify critical isthmus in atrial flutter (AFL) patients.  This triad is based in the Carto® electroanatomical mapping (EAM) version 7, which displays a histogram of the local activation times (LAT) of the tachycardia cycle length (TCL), in addition to the activation and voltage maps. This study aimed to prospectively assess the ability of an electrophysiological triad to identify and localize the AFL’s critical isthmus.

Methods

Prospective analysis of a unicentric registry of individuals who underwent left AFL ablation with Carto® EAM. All patients with non-left AFL, lack of high-density EAM, less than 2000 collected points or lack of mapping in any of the left atrium walls or structures were excluded. Ablation sites of arrhythmia termination were compared to an electrophysiological triad constituted by: areas of low-voltage (0.05 to 0.3mV), sites of deep histogram valleys (LAT-Valleys) with less than 20% density points relative to the highest density zone and a prolonged LAT-Valley duration that included 10% or more of the TCL. The longest LAT-Valley was designated as the primary valley, while additional valleys were named as secondary.

Results

A total of 12 patients (9 men, median age 72 IQR 67-75 years) were included. All patients presented with left AFL and 67% had a previous atrial fibrillation and/or flutter ablation. The median TCL and number collected points were 250 (230─290) milliseconds and 3150 (IQR 2340─3870) points, respectively. All AFL presented with at least 1 LAT-Valley in the analysed histograms, which corresponded to heterogeneous low-voltage areas (0.05 to 0.3mV) and encompassed more than 10% of TCL. Eleven of the 12 patients presented with at least 1 secondary LAT-Valley. All arrhythmias were effectively terminated after undergoing radiofrequency ablation in the primary or the secondary LAT-Valley location.

Conclusion

In a prospective analysis, an electrophysiological triad was able to identify the AFL critical isthmus in all patients. Further studies are needed to assess the usefulness of this algorithm to improve catheter ablation outcomes.

Mercury distribution and enrichment in coastal sediments from different geographical areas in the North Atlantic Ocean

This study evaluated mercury (Hg) in three coastal areas in the North Atlantic Ocean (Azores archipelago, Northwest Portugal and Southeast Mexico) and calculated their enrichment factor and geoaccumulation index. Hg presented greater affinity with fine sediment fraction. In all sampling areas the sites with proximity to possible Hg hotspots presented increased [Hg] in fine sediments. However, this fraction only represents less than 1% of the whole sediment, resulting in a significantly lower [Hg] in the total sediment fraction. After comparing [Hg] in the fine fraction and the values established by the Sediment Quality Guidelines, two sites in the Azores exceeded these values. Nevertheless, when considering the total sediment fraction, adverse biological effects are not expected to occur. Finally, both enrichment factor and geoaccumulation index indicated that the Hg present in 86% comes from natural sources and only sampling sites close to potential hotspots showed some degree of enrichment and contamination.

Water temperature modulates mercury accumulation and oxidative stress status of common goby (Pomatoschistus microps)

Mercury (Hg) is a widespread pollutant across estuarine and coastal areas, raising concern on its potential impact on aquatic organisms. Hg may origin from natural and anthropogenic sources, being persistent and potentially toxic to biota, ultimately representing a serious risk to human health. Hg accumulation and toxicity may also induce reactive oxygen species (ROS) production in marine organisms, responsible for cell and tissue damage. Additionally, the temperature is undoubtedly an important environmental factor to consider regarding accumulation, due to its marked influence on the physiology and ecology of aquatic organisms. This study aimed to investigate the effect of different temperature scenarios (15, 20 and 25 °C) on the Hg accumulation in Pomatoschistus microps (Krøyer, 1838) liver and muscle, as well as on oxidative stress responses and energy metabolism, after short-term exposure to a naturally contaminated sediment with an environmentally relevant [Hg] (1.2 μg g^-1). The results showed that Hg accumulation tends to increase along the temperature gradient with higher values of Hg accumulated in liver than in muscle tissue. The action of antioxidant enzymes and stress proteins seems to be effective in combating oxidative stress in the liver. Despite the action of antioxidant defences in the muscle, oxidative damage was observed at the protein level concomitantly with a decrease in aerobic energy production after exposure to Hg at higher temperatures. These findings are ecologically relevant and highlight the importance of further investigation of combined effects of Hg and other stressors, especially in a scenario of a changing climate where events leading to rapid alterations on water parameters are more frequent.

Specific cutaneous infiltrates in patients with haematological neoplasms: a retrospective study with 49 patients

BACKGROUND

Haematological neoplasms account for around 9% of all cancers, and they are recognised as an important cause of skin infiltration. However, studies analysing cutaneous metastasis of haematological neoplasms are scarce. We describe the clinical spectrum and outcomes of specific cutaneous manifestations of leukaemias, lymphomas, multiple myeloma (MM), and blastic plasmacytoid dendritic cell neoplasm (BPDN) and make a review of the literature.

METHODS

Data from 49 patients diagnosed with secondary cutaneous infiltration of systemic haematological neoplasms over the last 10 years in a tertiary dermatology centre were retrospectively collected, and clinical-evolutive features were analysed.

RESULTS

Most cases were lymphoma (44.9%, n = 22), followed by leukaemia cutis (38.8%, n = 19), secondary plasmacytoma (10.2%, n = 5) and BPDN (6.1%, n = 3). Nodules were the predominant type of lesion, and most patients presented with multiple (≥3) lesions. In 51% (n = 25) of cases, cutaneous infiltration was detected before the diagnosis of the underlying malignancy. The patients in diverse nosological groups did not differ in terms of survival (P = 0.052).

CONCLUSIONS

We recognise the clinical heterogeneity of specific cutaneous infiltrates. The high proportion of cases in which skin involvement was key to the diagnosis of systemic malignancy emphasises the role of the dermatologist in recognising and correctly managing these patients.

Coats plus syndrome (cerebroretinal microangiopathy with calcifications and cysts-1): A case report

We present a 6-year-old girl with skin hyperpigmentation, leukoplakia, and onychodystrophy, the classic mucocutaneous triad usually associated with dyskeratosis congenita. The patient also had premature graying of the hair, bone marrow failure, hepatitis, exudative retinopathy, osteopenia with multiple long bone fractures, and intracranial calcifications and brain cysts. Coats plus syndrome is a rare disease with a clinical and genetic overlap with dyskeratosis congenita. This disease is reviewed, with a focus on the pathogenesis of the genetic anomalies and its background as a telomere biology disorder.

Epicardial adipose tissue and atrial fibrillation: guilty as charged or guilty by association?

Background

Epicardial adipose tissue (EAT) has been linked to the presence and burden of atrial fibrillation (AF). However, it is still unclear whether this relationship is causal or simply a surrogate marker of other risk factors commonly associated with AF.

Purpose

The purpose of this study was to assess the relationship between these factors and EAT, and to compare their performance in predicting AF recurrence after an ablation procedure.

Methods

We assessed 575 consecutive patients (mean age 61±11 years, 62% male) undergoing AF ablation preceded by cardiac CT in a high-volume ablation center. EAT was measured on cardiac CT using a modified simplified method. Patients were divided into 2 groups (above vs. below the median EAT volume). Cox regression was used to assess the relationship between epicardial fat, risk factors, and AF relapse.

Results

Patients with above-median EAT volume were older (p<0.001), more often male (OR 1.7, p=0.002), had higher body mass index, and higher prevalence of smoking, hypertension, diabetes and dyslipidemia (p<0.05). Non-paroxysmal AF was also more common in those with above-median EAT volume. During a median follow-up of 18 months, 232 patients (40.3%) suffered AF recurrence. After adjustment for BMI and other univariate predictors of relapse, three variables emerged independently associated with time to AF recurrence: non-paroxysmal AF (HR 2.1, 95% CI: 1.5–2.7, p<0.001), indexed left atrial (LA) volume (HR 1.006 per mL/m2, 95% CI: 1.002–1.011, p<0.001), and indexed epicardial fat volume (HR 1.87 per mL/m2, 95% CI: 1.66–2.1, p<0.001). None of the classic cardiovascular risk factors were an independent predictor of AF recurrence (all p>0.10).

Conclusion

Classic cardiovascular risk factors are more prevalent in patients with higher amounts of epicardial fat. However, unlike these risk factors, EAT is a powerful predictor of AF recurrence after ablation. These findings suggest that EAT is not merely a surrogate marker, but an important participant in the pathophysiology of AF.

EAT, cvrf and AF burden

Funding Acknowledgement

Type of funding source: None

Idiopathic HFrEF. Is there room left for defibrillators?

Background and aim

Prophylactic implantation of an implantable cardioverter-defibrillator (ICD) is class 1 recommendation for heart failure (HF) patients with reduced ejection fraction (HFrEF) even though its proven advantage is weaker among nonischemic aetiology. In fact, in an era where both optimal medical therapy (OMT) and cardiac resynchronization therapy (CRT) significantly reduce sudden cardiac death (SCD), it is questionable whether ICD still have additional value. The aim of this study was to assess the current benefit of ICDs in preventing sudden cardiac death through resuscitated cardiac arrest (RCA), appropriate therapy for sustained ventricular tachycardia (VT) or fibrillation (VF) in a contemporary population of idiopathic HFrEF patients.

Methods

Single-centre retrospective study of consecutive symptomatic (NYHA class II to IV) idiopathic HFrEF patients with an ICD (either alone or in association with CRT), and remote monitoring with the corresponding software (MerlinTM, LatitudeTM, CarelinkTM, MicroPortTM or BiotronikTM) to assure appropriate event supervising. Idiopathic aetiology was assumed after excluding other probable causes. Coronary angiogram was required to exclude ischemic aetiology. Only those with prophylactic ICD implantation were included. RCA was defined as collapse with clinical signs of cardiac arrest and VF or VT appropriately terminated by ICD. In order to be sustained, VT episode had to have last at least 30 seconds.

Results

From 781 remote monitoring controlled patients, a total of 187 consecutive symptomatic idiopathic HFrEF patients with an ICD (125 men, mean age 64±18 years) were enrolled. Patients were on optimal medical therapy (ACEi/ARB: n=168, 90%; BB: n=154, 82%; mineralocorticoid antagonists: n=91, 49%; CRT: n=130, 70%; see Table). After a median follow-up of 99 months (IQR 62.2), RCA occurred in 10.7% (n=20) and 36.9% (n=69) had appropriately terminated VT. Both left ventricular ejection fraction (LVEF) improvement and CRT implantation did not independently reduce the incidence of RCA and VT requiring ICD therapy (OR, 1.02; 95% CI, 0.99–1.05; P=0.146 and OR, 0.85; 95% CI, 0.34–2.13; P=0.728; respectively). All cause mortality was 20 (10.7%). Inappropriate therapy was given as shocks to 41 patients (21.9%) and as antitachycardia pacing (ATP) to 30 (16%), opposing with appropriately given therapy to 43 (23%) and 63 (33.7%) patients, respectively (see Figure), contributing to a net clinical benefit (NCB) of 18.8%, favouring ICD implantation.

Conclusion

In this contemporaneous real-world population of symptomatic idiopathic HFrEF patients, episodes of impending cardiac death were frequent. Prophylactic ICD implantation seems to have added further benefit reducing SCD on top of optimal medical therapy, LVEF improvement and coexisting CRT.

Funding Acknowledgement

Type of funding source: None

Epicardial fat volume outperforms classic clinical scores for predicting atrial fibrillation relapse after pulmonary vein isolation

Background

Epicardial adipose tissue has been implicated in the pathophysiology of atrial fibrillation (AF), but its relevance to clinical practice remains uncertain. The aim of this study was to compare the performance of the amount of epicardial fat with previously published clinical scores of AF-relapse risk after pulmonary vein isolation (PVI).

Methods

We assessed 575 patients (354 men, age 61±11 years, 449 paroxysmal AF) with symptomatic AF undergoing cardiac CT prior to a PVI procedure. Epicardial fat was quantified on contrast-enhanced images using a new simplified semi-automated method. The study endpoint was symptomatic and/or documented AF recurrence at 12 months. Epicardial fat was compared against the following scores: MB-LATER, APPLE, DR-FLASH, and ATLAS.

Results

Median follow-up was of 22 months (IQR 12–35), 232 patients relapsed, 130 patients (27%) within the first 12 months. After adjustment for BMI and other univariate predictors of relapse, three variables emerged independently associated with time to AF recurrence: non-paroxysmal AF (HR 2.03, 95% CI: 1.53–2.69, p<0.001), indexed left atrial (LA) volume (HR 1.02 per mL/m2, 95% CI: 1.01–1.02, p<0.001), and indexed pericardial fat volume (HR 1.55 per mL/m2, 95% CI: 1.43–1.67, p<0.001). Based on the ROC curve analysis, the epicardial fat showed greater discriminative power, with a C-statistic of 0.76 (95% CI: 0.71–0.81) against 0.67 (p=0.007 for pairwise comparison of ROC curves), 0.67 (p=0.01), 0.63 (p<0.001) and 0.57 (p<0.001) for the MBLATER, APPLE, DR-FLASH and ATLAS scores, respectively. The C-statistic for indexed LA volume and non-paroxysmal AF AUC were of 0.63 (p<0.001) and 0.61 (p<0.001), respectively.

Conclusion

Pericardial fat volume is a strong independent predictor of AF relapse after PVI, outperforming clinical scores of post-PVI AF. The underlying mechanisms of this association deserve further study.

ROC Curve Analysys

Funding Acknowledgement

Type of funding source: None

Prevalence of LAA thrombus in patients undergoing percutaneous ablation of atrial fibrillation

Introduction

Computed tomography (CT) is often performed before atrial fibrillation (AF) ablation to assess the anatomy of the pulmonary veins and exclude left atrial (LA) and left atrial appendage (LAA) thrombus. With the growing use of new oral anticoagulants (NOACs), a reassessment of the need for systematic thrombus exclusion in this context seems warranted.

Objective

To evaluate the prevalence of thrombus in LA/LAA in pre-ablation CT in a contemporary cohort of patients predominantly anticoagulated with NOACs.

Methods

We evaluated 789 consecutive patients (mean age 61±12 years; 38% female; 84% with paroxysmal AF) who underwent pre-ablation CT between Oct/2015 and Oct/2019. ECG-gated CT-angiography was performed using a dual-source 64-slice CT after iodinated contrast injection. Whenever necessary, a second dedicated acquisition was made 60 seconds after the first set of images. Presence of thrombus was defined as a persistent opacification defect. For each patient, thromboembolic risk was assessed with the CHA2DS2-VASc score.

Results

The median interval between CT and AF ablation was 1 day (IQR 1 – 2 days). The median CHA2DS2-VASc was 2 points (IQR 0 – 3 points), with 590 patients (75%) having CHA2DS2-VASc ≥1. Among the 199 patients (25%) with CHA2DS2-VASc = 0, 118 (59,3%) were anticoagulated with a NOAC and 14 (7%) with a vitamin K antagonist; 67 (34%) were not anticoagulated. Conversely, amongst the 590 patients with CHA2DS2-VASc ≥1, 84% were anticoagulated with a NOAC (n=494), 11% used vitamin K antagonists (n=62), and 34 patients were not anticoagulated (23 with CHA2DS2-VASc = 1). On cardiac CT, 521 (66%) patients were in sinus rhythm. Overall, only one LAA thrombus was found (0.12% [1/789]; 95% CI: 0.0–0.7%) – in a patient with CHA2DS2-VASc = 0, anticoagulated with a NOAC. The median effective radiation dose was 3.2 mSv (IQR 2.1–4.8 mSv). There were 5 minor allergic reactions to iodinated contrast. No strokes were documented within the first 24 hours after ablation.

Conclusion

In this contemporary cohort of patients with predominantly paroxysmal AF and anticoagulated with NOAC, the prevalence of intracavitary thrombus was extremely low (0.12%). While these findings do not compromise the multipurpose role of pre-ablation CT, they should nevertheless inform future discussions on the risk/benefit and cost/benefit of performing systematic exclusion of LA/LAA thrombi prior to AF ablation.

Funding Acknowledgement

Type of funding source: None

A machine-learning algorithm to predict atrial fibrillation recurrence after a pulmonary vein isolation procedure

Background

Contemporary risk models to predict the recurrence of atrial fibrillation (AF) after pulmonary vein isolation have limited predictive ability. Models with high specificity seem particularly suited for the setting of AF ablation, where they could be used as gatekeepers to withhold intervention in patients with low likelihood of success. Machine learning (ML) has the potential to identify complex nonlinear patterns within datasets, improving the predictive power of models. This study sought to determine whether ML can be used to better identify patients who will relapse within one year of an AF ablation procedure.

Methods

We assessed 484 patients (294 men, mean age 61±12 years, 76% with paroxysmal AF) who underwent radiofrequency pulmonary vein isolation (PVI) for symptomatic drug-refractory AF. Using this dataset, a machine-learning model based on Support Vector Machines (SVM) was developed to predict AF recurrence within one year of the procedure. The following variables were used to feed the model: type of AF (paroxysmal vs. non-paroxysmal), previous ablation procedure, left atrium (LA) volume, and epicardial fat volume (both derived from pre-ablation cardiac CT). The algorithm was trained in a random sample of 70% of the study population (n=339) and tested in the remainder 30% (n=145).

Results

A total of 130 patients (27%) suffered AF recurrence within one year of the procedure. The ML model predicted AF recurrence with 75% accuracy (95% CI 67–82%), yielding a sensitivity and specificity of 25% (95% CI 13–41%) and 94% (95% CI 88–98%), respectively. The corresponding positive and negative predictive values were 62% (95% CI 39–81%) and 77% (95% CI 67–82%), respectively. The relative weight of the variables in the ML model was: epicardial fat 56%, type of AF 23%, previous ablation 14%, and LA volume 7%. A high-risk subgroup representing 10.8% of patients was identified with the ML algorithm. In this subgroup, one-year recurrence was 62%, representing 24% of the total number of recurrences.

Conclusion

A machine-learning model showed high specificity in the identification of patients who relapse during the first year after AF ablation. In the future, these tools may be useful to improve patient selection.

Funding Acknowledgement

Type of funding source: None

Relationship between epicardial fat and left atrium fibrosis in patients with atrial fibrillation

Background

Epicardial adipose tissue (EAT) has recently been shown to be associated with the presence, severity, and recurrence of atrial fibrillation (AF). Although the pathophysiological mechanisms underlying this association remain to be established, several hypotheses have been put forward, including direct adipocyte infiltration, oxidative stress, and the secretion of adipokines causing inflammation and fibrosis of atrial tissue. We hypothesized that the volume of EAT and the amount of left atrium (LA) fibrosis assessed by non-invasive imaging would be significantly correlated in patients with AF, and that both would predict time to relapse after pulmonary vein isolation (PVI).

Methods

Sixty-eight patients with AF being studied for a first PVI procedure underwent both cardiac computerized tomography (CT) and cardiac magnetic resonance (CMR) within less than 48h. EAT was quantified on contrast-enhanced CT images. LA fibrosis was quantified on isotropic 1.5mm 3D delayed enhancement CMR for image intensity ratio values >1.20. Radiofrequency PVI was performed using an irrigated contact force-sensing ablation catheter, guided by electroanatomical mapping. After PVI, patients were followed for AF recurrence, defined as symptomatic or documented AF after a 3-month blanking period. Pearson's correlation coefficient was used for gauging the correlation between EATLM volume and LA fibrosis. The relationship between these two variables and time to AF recurrence was assessed by Cox regression.

Results

Most of the 68 patients (46 men, mean age 61±12 years) had paroxysmal AF (71%, n=48). The mean body mass index (BMI) was 28.0±4.0 kg/m2. Patients had a median EATLM volume of 2.4 cm3/m2 [interquartile range (IQR) 1.6–3.2 cm3/m2], and a median estimated amount of LA fibrosis of 8.9 g (IQR 5–15 g), corresponding to 8% (IQR 5–11%) of the total LA wall mass. The correlation between EATLM and LA fibrosis was statistically significant but weak (Pearson's R = 0.38, P=0.001) – Figure 1. During a median follow-up of 22 months (IQR 12–31), 31 patients (46%) suffered AF recurrence. Four predictors of relapse were identified in univariate Cox regression: EATLM (HR 2.19, 95% CI 1.65–2.91, P<0.001), LA fibrosis (HR 1.05, 95% CI 1.01–1.09, P=0.033), non-paroxysmal AF (HR 3.36, 95% CI 1.64–6.87, P=0.001), and LA volume (HR 1.03, 95% CI 1.01–1.06, P=0.006). Multivariate analysis yielded two independent predictors of time to AF relapse: EATLM (HR 2.05, 95% CI 1.51–2.79, P<0.001), and non-paroxysmal AF (HR 2.36, 95% CI 1.08–5.16, P=0.031).

Conclusion

The weak correlation between EAT and LA suggests that LA fibrosis is not the main mechanism by which EAT and AF are linked. EAT was more strongly associated with AF recurrence than LA fibrosis, which supports the existence of other, more important mediators between EAT and this arrhythmia.

Correlation between EAT and LA

Funding Acknowledgement

Type of funding source: None

Catheter ablation in atrial fibrillation: comorbidities and mortality from high-volume centers

Background

Catheter ablation (CA), has gained wider acceptance as an attractive option for treating symptomatic AF. Although traditionally seen as a safe procedure, there is limited and conflicting data on procedure-related early morbimortality, with new evidence suggesting early mortality may be as high as 0.5%-1%.

Purpose

We aimed to assess the rates of early and late morbimortality of post-atrial fibrillation (AF) ablation in high-volume centers.

Methods

Prospective registry of 2 high-volume ablation centers, comprising 3722 consecutive patients (mean age 61.1±11.2, 66.4% male, n=2471), who underwent AF ablation from 2005 to 2019. Early mortality was defined as death during initial admission or during the first 45 days after ablation. Median follow-up time was 5.4 years.

Results

Most patients were treated with radiofrequency (97%) while 3% were treated with cryoablation. Early mortality was 0.08% (n=3), with a median time from ablation to death of 22 days. Cumulative mortality at 3, 6 and 12 months was 0.08%, 0.16% and 0.19%, respectively. At 3 and 5 years, mortality remained low at 0.48% and 0.73%, respectively. Early mortality was higher among patients who had suffered procedural complications (fistula and stroke, p<0.001). Among the latter, pericardial effusion and tamponade were the most frequently found (0.6%, n=24), only 1 of which required emergent surgical drainage and myocardial repair. Early ischemic stroke occurred in 2 patients (0.1%). Other less frequent complications were atrio-esophageal fistula (0.1%, n=2), phrenic nerve palsy (0.1%, n=2), anoxic encephalopathy following cardiac arrest (0.03%, n=1) and pulmonary vein stenosis (0.03%, n=1).

Conclusion

Early mortality following ablation is very low (<0.1%), when performed by an experienced high-volume team. Severe complications are rare (<1%) and mostly amenable to treatment. Our findings reaffirm the overall safety of AF ablation.

AF catheter ablation morbimort

Funding Acknowledgement

Type of funding source: None

Combined endocardial and epicardial ventricular tachycardia ablation for ischemic and nonischemic dilated cardiomyopathy

Background

Patients with ischemic (IHD) and nonischemic (NICM) dilated heart disease and reduced left ventricular ejection fraction are at increased risk of ventricular tachycardias (VTs) or sudden cardiac death. VT catheter ablation is an invasive treatment modality for antiarrhythmic drugs-resistant VT that reduces arrhythmic episodes, improves quality of life and improves survival in patients with electrical storm. Direct comparison of the outcomes from combined and non-combined endoepicardial ablations is limited by patient characteristics, follow-up durations, protocols heterogeneity and scarcity of randomized trials. We aim to investigate the long-term clinical outcomes of these 2 strategies in the IHD and NICM populations.

Methods

Multicentric observational registry including 316 consecutive patients who underwent combined (C-ABL) and non-combined (NC-ABL) endoepicardial ventricular tachycardia (VT) ablation for drug-resistant VT between January 2008 and July 2019. Chagas' disease patients were excluded. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-days mortality and procedure-related complications.

Results

Most of the patients were male (85%), with IHD (67%) and a mean age of 63±13 years. During a mean follow-up of 3±2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified storm (ES) at presentation (HR=2.17; 95% CI 1.44–3.25), IHD (HR=0.53, 95% CI 0.36–0.78), left ventricular ejection fraction (LEVF) (HR=0.97, 95% CI 0.95–0.99), New York Heart Association (NYHA) functional class III or IV (HR=1.79, 95% CI 1.13–2.85) and C-ABL (HR=0.49, 95% CI 0.27–0.92) as independent predictors of VT recurrence. In 135 patients undergoing two or more ablation procedures only C-ABL (HR=0.36, 95% CI 0.17–0.80) and ES at presentation (HR=2.42, 95% CI 1.24–4.70) were independent predictors of arrhythmia recurrence. The independent predictors of all-cause mortality were ES (HR=2.17, 95% CI 1.33–3.54), LVEF (HR=0.95, 95% CI 0.92–0.98), age (HR=1.03, 95% CI 1.01–1.05), NYHA functional class III or IV (HR=2.04, 95% CI 1.12–3.73), and C-ABL (HR=0.22, 95% CI 0.05–0.91). The survival benefit was only seen in patients with a previous ablation (P for interaction=0.04) – Figure 1. Mortality at 30-days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P=0.777), as was the complication rate (10.3% vs. 15.1% respectively, P=0.336).

Conclusion

A combined endo-epicardial approach appears to be associated with greater VT-free survival and overall survival in ischemic and nonischemic patients undergoing repeated VT catheter ablations. Both strategies seem equally safe.

Survival analysis for C-ABL vs NC-ABL

Funding Acknowledgement

Type of funding source: None

Conradi-Hünermann-Happle syndrome: report of a novel heterozygous mutation on the emopamil-binding protein gene, c.333delC

Conradi-Hünermann-Happle Syndrome, also called X-linked rhizomelic chondrodysplasia punctata, is a rare genodermatosis that presents with cutaneous, skeletal, and ophthalmological abnormalities. Herein, we report a full-term newborn that presented at birth with scattered blaschkolinear bands of adherent scales and scalp erosions in a spiral distribution. Genetic analysis of emopamil-binding protein gene revealed a previously undescribed heterozygous mutation of c.333delC.

Mercury bioaccumulation in the long-fin squid Loligo forbesi near the Mid-Atlantic Ridge: Implications to human exposure

Due to growing commercial interest as a fishing resource and its intermediate position in the marine trophic chains as both prey and predator, cephalopods can play an important role in mercury (Hg) transfer along the marine food webs, since they can bioaccumulate this metal in its tissues. Our study aims to analyze Hg accumulation in Loligo forbesi caught in the Azores Archipelago (Portugal) quantifying Hg in different tissues (mantle and stomach), as well in the squid stomach content, in order to evaluate the efficiency of Hg transfer from prey to predator. Hg data from the tissues was used to estimate the weekly tolerable Hg intake due to squid consumption. Overall data indicate that Hg measured in the stomach tissue (0.1 ± 0.01 μg g^-1) was significantly higher than Hg levels found in the mantle (0.04 ± 0.001 μg g^-1) and stomach contents (0.01 ± 0.001 μg g^-1). BMF (bioaccumulation factor) was >1 for all the samples, indicating a biomagnification process from prey to predator. Hg concentration in the mantle tissue was correlated with mantle size; although females present higher Hg levels than males, the difference was found to be not related to gender but rather to the fact that females had larger bodies. Finally, considering the Hg concentration found in the mantle and the permitted Hg levels, it is advisable to consume up to 1050-1890g of squid per week, according to the regulatory agencies. Thus, our results indicate that, since these doses are respected, consumption of squids from the Azorean waters do not pose a risk to humans.

P1508A single center analysis of a 10-year period of lead removal

BACKGROUND

The number of lead removal of cardiac implantable electronic devices (CIED) has increased in recent years. The recent European registry (ELECTRa) did not include all European centers and not all lead extractions are possible to be performed transvenously.

AIMS

We aim to analyze all lead extraction procedures (transvenous or open surgery) performed in our center and the short- and long-term follow-up of these patients (pts).

METHODS

We retrospectively reviewed all lead extractions performed from 2008 to 2017. We analyzed pts´ characteristics (personal history, cardiovascular risk factors, indication for device implantation, laboratory tests); indications for extraction; techniques used and personnel that participate in the procedure, complications peri- and post-procedural and short and long-term follow-up.

RESULTS

A total of 189 pts (330 leads) were included (mean 69 ± 14 years, 73% male).  The follow-up was 54 (IQR 20-87) months. Median time after implant was 47 (IQR 19-98) months. Lead explant was performed in 30 patients (16%) and lead extraction (at least one lead implanted >1 year or a lead requiring assistance of specialized equipment) in 159 (84%). Indications for removal are presented in figure A. In those who were infected, isolation of the microorganism was possible in 35% and Staphylococcus aureus was the most common agent (51%). 101 procedures (53%) occurred in the operating room, while 89 (47%) were performed in the electrophysiology laboratory, but 47% of those with the participation of a surgeon. On the total, cardiac surgeons were responsible for 75% of the procedures. Removal was tried in 330 leads (98 atrium lead, 199 right ventricle lead (79 defibrillator lead) and 33 coronary sinus lead). Of those, 298 were completely removed, 14 were partially removed (<4cm of a lead remained in the patient body) and 18 were not removed (radiologic failure). On an individual patient basis, clinical success was achieved in 185 patients (97%). Techniques used in the 330 leads were distributed in figure B.  Surgical approach was necessary in 14 pts due to unsuccessful transvenous removal (n = 3), large vegetation in the lead (n = 4), concomitant valvular endocarditis (n = 2), other indication for open surgery (n = 4) and complicated transvenous removal (n = 1). Complications occurred in 6 patients: 3 persistent infections, 1 stroke, 2 vessel rupture. Related-procedural mortality was 1.5% (n = 3). The long-term survival of pts who performed open heart surgery was not different from those who underwent transvenous lead removal (logrank, p = 0.27) (figure C).

CONCLUSION

Although being a low volume center (19 procedures/year) and including pts with transvenous and open surgery, lead removal was associated with a high success rate with low all cause complication and mortality rates. Emergent surgery due to acute complications was very rare (0.5%) and open heart surgery was mostly programmed and not associated with a worse outcome.

Abstract Figure.

P5693Critical sites for scar-related ventricular tachycardias treatment: an approach based on sinus rhythm late activation zones

Introduction

Despite advances in antiarrhythmic and device therapy, ventricular tachycardia (VT) is a major cause of increased morbidity and mortality. During scar-mediated monomorphic VT ablation, the search for critical isthmus sites continues to be the primary goal during successful ablative procedures. However, catheter ablation based on conventional mapping techniques is associated with low success rates and is limited to patients with stable VT.

Objective

The aim of the study was to evaluate, in patients with history of VT, the success of a strategy based on substrate mapping and ablation during sinus rhythm.

Methods

Retrospective single center analysis of patients undergoing VT ablation from November 2015 to November 2017. Clinical profiles and procedural details were determined. We used high-density structural map to identify voltage abnormalities as well a functional map of sinus rhythm activation to identify the regions of late potentials. Radiofrequency applications were performed in the areas with the latest activation. Recurrence of VT was considered the end-points of the follow-up.

Results

A total of 22 patients were included in the analysis, 95% male, with an median age of 65,5 (57–71) years old. The majority of the patients (18) with ischemic cardiomyopathy, 3 with nonischemic cardiomyopathy, and 1 with arrhythmogenic right ventricular cardiomyopathy were included. Epicardial mapping was performed in 27% of the cases. CARTO mapping system was used in 10 patients and Rhythmia in the remaining cases. Areas with the latest activation corresponded to regions of abnormal voltage in 21 patients. During a 26,5 (21,5–29,3) months of follow-up, the observed VT recurrence rate was 35%. 25% of the patients needed hospital admission due to arrhythmias and one patient died due to an arrhythmic cause. Treatment success was higher in epicardial approach (100% VS 50%, p=0,03). The location of the scar in the left ventricle was not a determinant of success (anterior-66,7% VS lateral/inferior-61,5%, p=0,806).

Conclusion

A substrate-based approach that targets regions of late activation within the scar seems attractive and may be a simple way to perform VT ablation with success. In our population, this strategy seams successful, especially in epicardial approach. Substrate modification strategies aiming to eradicate all potential reentrant circuits may be the most successful way to treat VT and avoid recurrences.

P2849Prevalence and significance of sustained pulmonary vein isolation in repeat AF ablation procedures

Introduction

Pulmonary vein (PV) reconnection is a common cause of relapse after catheter ablation of atrial fibrillation (AF). However, some patients have AF recurrence despite durable PV isolation. The aim of this study was to assess the PV isolation status at the time of a second catheter ablation (redo) procedure, and its relationship with subsequent AF relapse.

Methods

Consecutive patients with symptomatic drug-resistant AF who underwent redo procedures from January 2006 to December 2017 were identified in a single-center observational registry. Pulmonary vein isolation status was assessed during the electrophysiologic study with a circular mapping catheter. Additional radiofrequency (RF) energy applications were also recorded. AF relapse was defined as symptomatic or documented AF/atrial tachycardia/atrial flutter after a 3-month blanking period.

Results

We identified 240 patients (77 [32%] females, median age 61 [IQR 53–67] years, 85 [35%] with non-paroxysmal AF) undergoing redo procedures during the study period. At the time of redo, 17 (7%) of the patients presented bidirectional conduction block of all PVs. PV reconnection occurred in 157 (65%) of cases in the left superior vein, 142 (59%) in the left inferior vein, 177 (73%) in the right superior vein, and 163 (68%) in the right inferior vein (table). All of the PVs were reconducted in 91 (38%) patients. Additional RF applications were performed in the left atrium (LA) roof, LA posterior wall, cavotricuspid isthmus, mitral isthmus, superior vena cava, coronary sinus, and left atrial appendage ostium, at the operator's discretion (table 1).

Over a median follow-up of 2-years (IQR 1–5), 126 patients (53%) suffered AF recurrence, yielding a mean relapse rate of 17%/year. In multivariate Cox regression analysis, the lack of PV reconnection at the time of redo emerged as an independent predictor of subsequent relapse (HR 1.97, 95% CI 1.12–3.49, p=0.019) even after adjustment for univariate predictors including non-paroxysmal AF, body mass index, female sex, and active smoking.

Conclusion

In patients undergoing redo AF ablation procedures, less than 10% present with complete PV isolation. Despite being relatively infrequent, this finding is independently associated with greater likelihood of subsequent recurrence, suggesting that other mechanisms, not fully addressed by additional RF applications, are at play.

P5699Endocardial vs. epicardial ventricular tachycardia ablation: a propensity score matched analysis

Introduction

Direct comparisons of long-term clinical outcomes of endocardial vs. epicardial catheter ablation techniques for drug-resistant ventricular tachycardia (VT) have been scarcely reported.

We aim to compare the long-term efficacy and safety of endocardial vs. epicardial catheter ablation (END-ABL and EPI-ABL, respectively) in a propensity score (PS) matched population.

Methods

Single-center observational registry including 215 consecutive patients who underwent END-ABL (181) or EPI-ABL (n=34) for drug-resistant VT between January 2007 and June 2018. Efficacy endpoint was defined as VT-free survival after catheter ablation, while safety outcomes were defined by 30-days mortality and procedure-related complications. A propensity score was used to match patients in a 1:1 fashion according to the following variables: VT storm at presentation, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class III/IV at presentation, ischemic ethology, presence of implantable cardioverter-defibrillator (ICD), and previous endocardial catheter ablation. Independent predictors of VT recurrence were assessed by Cox regression.

Results

The PS yielded two groups of 31 patients each well matched for baseline characteristics (Table 1). Over a median follow-up of 2 years (IQR 1–3), 58% (n=18) ENDO-ABL patients had VT recurrence vs. 26% (n=8) in the EPI-ABL group (P=0.020). The yearly rates of VT recurrence were 28%/year for END-ABL vs. 11%/year for EPI-ABL (P=0.021). Multivariate survival analysis identified previous endocardial ablation (HR= 3.52; 95% CI 1.17–10.54, p=0.026) and VT storm at presentation (HR=3.57; 95% CI 1.50–8.50, p=0.004) as independent predictors of VT recurrence. EPI-ABL was independently associated with fewer VT recurrences (HR=0.28; 95 CI 0.12–0.69, p=0.005), but only in patients with a previous endocardial ablation (p for interaction = 0.004) – Figure A.

No patients died at 30-days post-procedure. Hospital length of stay was similar between END-ABL and EPI-ABL (5 vs. 4 days respectively, p=0.139), as was the complication rate (6.5% vs. 12.9% respectively, p=0.390), although driven by different causes (Table 1).

Conclusion

VT storm at presentation and previous catheter ablation were independent predictors of VT recurrence. In patients with a previous failed endocardial catheter ablation, epicardial ablation seems to provide greater VT-free survival than repeat endocardial ablation. Both strategies seem equally safe.

1204Pericardial fat volume outperforms classic risk markers in the prediction of relapse after pulmonary vein isolation

Introduction

Pericardial adipose tissue has been implicated in the pathophysiology of atrial fibrillation (AF), but its relevance to clinical practice remains uncertain. The aim of this study was to assess the relative importance of pericardial fat as predictor of recurrence after pulmonary vein isolation (PVI).

Methods

We assessed 453 patients (278 men, age 61±13 years, 348 paroxysmal AF) with symptomatic AF undergoing cardiac CT prior to a PVI procedure. Pericardial fat was quantified on contrast-enhanced images using a new simplified semi-automated method. The study endpoint was symptomatic and/or documented AF recurrence.

Results

Over a median follow-up of 14 months (IQR 7–23), 170 patients (38%) relapsed. Survival analysis showed significant differences in AF-free survival across tertiles of pericardial fat (Figure). Pericardial fat volume was weakly correlated to body mass index [(BMI), Pearson's R=0.34]. After adjustment for BMI and other univariate predictors of relapse, three variables emerged independently associated with time to AF recurrence: non-paroxysmal AF (HR 2.08, 95% CI: 1.51–2.87, p<0.001), indexed left atrial (LA) volume (HR 1.02 per mL/m2, 95% CI: 1.01–1.02, p<0.001), and indexed pericardial fat volume (HR 1.50 per mL/m2, 95% CI: 1.37–1.64, p<0.001). Based on the Wald test, indexed pericardial fat volume was the strongest of these predictors of relapse (X2 values of 20, 13, and 77, respectively). The population attributable risk (PAF) was higher for pericardial fat (PAF=37% for 1st vs 4th quartile) vs LA volume (PAF=11% for 1st quartile vs 4th quartile) and non-paroxysmal AF (PAF=23%). Pericardial fat volume also showed greater discriminate power than indexed LA volume, with a C-statistic of 0.80 (95% CI 0.76–0.85) vs. 0.61 (95% CI 0.55–0.66), p for difference <0.001. The method for quantifying pericardial fat showed high inter-observer reproducibility (Pearson's R=0.90) and was quick to perform (38±3 seconds).

Conclusion

Pericardial fat volume is a strong independent predictor of AF relapse after PVI, outperforming classic risk markers such as LA volume and type of AF. The underlying mechanisms of this association deserve further study. Meanwhile, this simple parameter may help select patients who are more likely to derive sustained benefit from AF ablation.

Erythema nodosum and sarcoid granulomas - letting the cat out of the bag

A 41-year-old woman presented with a violaceous papule on the dorsum of the hand, large ipsilateral axillary lymphadenopathy, and tender, erythematous, subcutaneous nodules on the legs. Accompanying signs included fever, ankle swelling, and bilateral red eye. She recalled having a previous exposure to kittens one month before and had a positive family history for sarcoidosis. Histological examination of the hand lesion showed sarcoidal granulomas with positive Bartonella henselae DNA, whereas a biopsy done on the leg nodules was compatible with erythema nodosum. Cat scratch disease (CSD) typically presents as a tender regional lymphadenopathy preceded by an inoculation papule with spontaneous resolution occurring between 8-16 weeks. Cutaneous manifestations of CSD are rare, with erythema nodosum accompanying only 0.6% of cases. Although speculative, the background of a positive family history for sarcoidosis may explain the atypical presentation of this case, with red eye, persistent arthralgia, and associated sarcoidal granulomas.