Outcomes after cryoballoon ablation of paroxysmal atrial fibrillation with the PolarX or the Arctic front advance pro: a prospective multicentre experience

AIMS

The aim of this study was to compare procedural efficacy and safety, including 1-year freedom from AF recurrence, between the novel cryoballoon system PolarX (Boston Scientific) and the Arctic Front Advance Pro (AFA-Pro) (Medtronic), in patients with paroxysmal AF undergoing PVI.

METHODS AND RESULTS

This multicentre prospective observational study included 267 consecutive patients undergoing a first cryoablation procedure for paroxysmal AF (137 PolarX, 130 AFA-Pro). KM curves with the log-rank test was used to compare the 1-year freedom from AF recurrence between both groups. Multivariate Cox model was performed to evaluate whether the type of procedure (PolarX vs. AFA-Pro) had an impact on the occurrence of AF recurrences after adjustment on potentially confounding factors. The PolarX reaches lower temperatures than the AFA-Pro (LSPV 52 ± 5, vs. 59 ± 6; LIPV 49 ± 6 vs. 56 ± 6; right superior pulmonary vein: 49 ± 6 vs. 57 ± 7; right inferior pulmonary vein: 52 ± 6 vs. 59 ± 6; P < 0.0001). A higher rate of transient phrenic nerve palsy was found in patients treated with the PolarX system (15% vs. 7%, P = 0.05). After a mean follow-up of 15 ± 5 months, 20 patients (15%) had recurrences in AFA-Pro group and 27 patients (19%) in PolarX group (P = 0.35). Based on survival analysis, no significant difference was observed between both groups with a 12-month free of recurrence survival of 91.2% (85.1-95.4%) vs. 83.7% (76.0%-89.1%) (log-rank test P = 0.11). In multivariate Cox model hazard ratio of recurrence for PolarX vs. AFA-Pro was not significant [HR = 1.6 (0.9-2.8), P = 0.12].

CONCLUSION

PolarX and AFA-Pro have comparable efficacy and safety profiles for pulmonary veins isolation in paroxysmal atrial fibrillation.

Pre-implant predictors of inappropriate shocks with the third-generation subcutaneous implantable cardioverter defibrillator

AIMS

Despite recent improvements, inappropriate shocks emitted by implanted subcutaneous implantable cardioverter defibrillators (S-ICDs) remain a challenge in 'real-life' practice. We aimed to study the pre-implant factors associated with inappropriate shocks for the latest generation of S-ICDs.

METHODS AND RESULTS

Three-hundred patients implanted with the third-generation S-ICD system for primary or secondary prevention between January 2017 and March 2020 were included in this multicentre retrospective observational study. A follow-up of at least 6 months and pre-implant screening procedure data were mandatory for inclusion. During a mean follow-up of 22.8 (±11.4) months, 37 patients (12.3%) received appropriate S-ICD shock therapy, whereas 26 patients (8.7%) experienced inappropriate shocks (incidence 4.9 per 100 patient years). The total number of inappropriate shock episodes was 48, with nine patients experiencing multiple episodes. The causes of inappropriate shocks included supraventricular arrhythmias (34.6%) and cardiac (30.7%) or extra-cardiac noise (38.4%) oversensing. Using multivariate analysis, we explored the independent factors associated with inappropriate shocks. These were the availability of less than three sensing vectors during pre-implant screening [hazard ratio (HR), 0.33; 95% confidence interval (CI), 0.11-0.93; P = 0.035], low QRS/T wave ratio in Lead I (for a threshold <3; HR, 4.79; 95% CI, 2.00-11.49; P < 0.001), history of supraventricular tachycardia (HR, 8.67; 95% CI, 2.80-26.7; P < 0.001), and being overweight (body mass index > 25; HR, 2.66; 95% CI, 1.10-6.45; P = 0.03).

CONCLUSION

Automatic pre-implant screening data are a useful quantitative predictor of inappropriate shocks. Electrocardiogram features should be taken into consideration along with other clinical factors to identify patients at high risk of inappropriate shocks.

Atrial fibrillation detection by the subcutaneous defibrillator: real-world clinical performances and implications from a multicentre study

AIMS

No data exist concerning the clinical performances of the subcutaneous implantable cardioverter-defibrillator (S-ICD) atrial fibrillation (AF) detection algorithm. We aimed to study the performances and implications of the latter in a 'real-world' setting.

METHODS AND RESULTS

Between July 2017 and August 2019, 155 consecutive S-ICD recipients were included. Endpoint of the study was the incidence of de novo or recurrent AF using a combined on-site and remote-monitoring follow-up approach. After a mean follow-up of 13 ± 8 months, 2531 AF alerts were generated for 55 patients. A blinded analysis of the 1950 subcutaneous electrocardiograms available was performed. Among them 47% were true AF, 23% were premature atrial contractions or non-sustained AF, 29% were premature ventricular contractions or non-sustained ventricular tachycardia, and 1% were misdetection. Fourteen percent (21/155) patients had at least one correct diagnosis of AF by the S-ICD algorithm. One patient presented symptomatic paroxysmal AF not diagnosed by the S-ICD algorithm (false negative patient). Patient-based sensitivity, specificity, positive, and negative predictive values were respectively 95%, 74%, 38%, and 99%. Among patients with at least one correct diagnosis of AF, 38% (8/21) had subsequent clinical implications (anticoagulation initiation or rhythm control therapies).

CONCLUSION

The S-ICD AF detection algorithm yields a high sensitivity for AF diagnosis. Low specificity and positive predictive value contribute to a high remote monitoring-notification workload and underline the necessity of a manual analysis. Atrial fibrillation diagnosis by the S-ICD AF detection algorithm might lead to significant therapeutic adjustments.

Atrio-ventricular block on Wolff Parkinson White's syndrome: a rare association

Complete atrioventricular block (AV block) associated with an accessory pathway is a rare phenomenon. We report the case of a third degree AV block paired with a Wolff Parkinson White (WPW) syndrome in a 91-year-old patient. The electrocardiogram (ECG) on admission showed a Mobitz type II AV block alternating with a third degree block on a wide-QRS ventricular rhythm beating at 35 cycles per minute. The patient urgently underwent the implantation of a single-lead pacemaker. The post-implantation ECG revealed a Kent accessory pathway on the left posteroseptal site. The existence of a complete AV block in the presence of an accessory pathway implies a more or less permanent blockage of atrial depolarization, both through the normal conduction tissue and the accessory pathway.

Prognostic value of ST2 in myocardial infarction

INTRODUCTION

Soluble Suppression of Tumorigenicity 2 (ST2) is a biomarker of myocardial fibrosis increasingly recognized as a predictor of morbidity and mortality in heart failure. Its role in the prognosis after a myocardial infarction has not been validated to date.

AIM

To evaluate the prognostic value of ST2 for in-hospital morbidity and mortality after myocardial infarction.

METHODS

We conducted a longitudinal prospective study including 74 patients admitted for an acute uncomplicated cardiac myocardial infarction at Habib Thameur hospital between April and October 2016. ST2 blood samples were drawn until 72 hours post admission .The primary endpoint was the occurrence of a major cardiovascular event during hospitalization.

RESULTS

Patients' mean age was 61.28 ± 13 years-old with a sex ratio of 1.8. The reason for admission was acute coronary syndrome with persistent ST segment elevation in 54% of cases and non-ST segment elevation acute myocardial infarction in 46% of cases. The ST2 assay was positive in 78% of cases with a mean value of 122.43 ± 95.72 ng/ ml. Left ventricular dysfunction was observed in 47% of cases. Fifteen per cent of the patients had a 3 vessel-disease, 24% a 2 vessel-disease and 34% a 1 vessel-disease. Twenty-six percent had at least one major cardiovascular event. In-hospital mortality was 10%. In multivariate analysis, ST2 was an independent factor associated with the occurrence of major cardiovascular events (RR = 2, p = 0.04). The cutoff value of ST2 of 35 ng/ml had a sensitivity of 95%, a specificity of 30% (AUC = 0.672, CI 0.546-0.798, p = 0.024), a negative predictive value of 100% and a positive value of 33%. A significant correlation was found between ST2 and troponin, blood glucose on admission, CRP and left ventricular ejection fraction (respectively: r = 0.398, p <0.0001, r = 0.281, p = 0.015, r = 0.245, p = 0.039, r = -0.401, p <0.0001).

CONCLUSION

The measurement of ST2 after a myocardial infarction constitutes a new prognostic indicator of in-hospital morbidity and mortality.

Factors associated with poor medication compliance in hypertensive patients

INTRODUCTION

Hypertension is a major cause of cardiovascular morbidity and mortality. Despite therapeutic advances, only one-third of patients achieve blood pressure targets. Poor compliance is one of the main causes.

AIM

To study the factors associated with poor compliance in hypertensive patients.

METHODS

We conducted a descriptive prospective study including 200 hypertensive patients treated and followed out between March and April 2017. The Girerd medication adherence questionnaire was submitted to patients during an semi-directed interview.

RESULTS

Patients meanagewas of 63.28 ± 9.62 years-old and sex ratio of 0.92. The predominant risk factor was dyslipidemia in 45% of cases, followed by smoking 36.5% and diabetes 25.5%. A previous history of acute coronary syndrome was found in 33.5% of cases and atrial fibrillation in 13%. Fifteen percent of our patients consumed alcohol regularly and 9.5% practiced regular physical activity. Fifty-five percent of our patients were on low sodium diet. The prevalence of poor medication adherence was 20.5%. In multivariate analysis, independent factors related to poor medication adherence were: the number of treating specialist physicians greater than 1 (OR = 3.444, p = 0.008) and the absence of information received on hypertension (OR = 4.345; p= 0.003).

CONCLUSION

The improvement of medication adherence for our patients must be based on information on hypertension and its risks and the harmonization of care between treating physicians.

Evaluation of patients' knowledge on their vitamin K antagonist treatment

INTRODUCTION

Vitamin K antagonists (VKA) are currently the most prescribed oral anticoagulant treatment in Tunisia. Despite the standardization of biological monitoring and the better definition of therapeutic objectives, their side effects are a frequent reason for hospitalization.

AIM

To evaluate patients' knowledge about their VKA treatment.

METHODS

We realized a cross-sectional descriptive study in the Cardiology Department of HabibThameur Hospital from September to October 2016. A questionnaire consisting of 14 items was used in a semi-directed interview in order to assess patients' knowledge on their VKA treatment.

RESULTS

Our study included one hundred patients. Mean age was 61 ± 12 years and sex ratio of 1.8. Forty-eight per cent were illiterate. The median duration of AVK intake was 5 years. Atrial fibrillation (AF) was the most frequent indication (57%). Eighty percent of patients had more than five correct answers on the eight items of knowledge: VKA's name (96%), tablet description (93%), dose (99%), time (94%), VKA's effect (70%), INR (56%), treatment's risk (49%) and the target INR (20%). Twenty-two percent had more than four correct answers on the 6 items of know-how: what to do in case of haemorrhage (70%), what to do in case of oblivion (45%), interactions precautions to be observed with food (13%), activities advised against (49%) and medical procedures advised against (27%). In multivariate analysis, only prior VKA information was significantly associated with a better knowledge of VKA (p = 0.027).

CONCLUSION

Our patients' knowledge on their VKA treatment was insufficient to ensure the safety and efficacy of treatment. The creation of a therapeutic education program on is therefore necessary to reduce the iatrogenic risk of this treatment.

Atrial fibrillation and hypertension: State of the art

Atrial fibrillation and hypertension are often coexistent. Their incidence increases with advancing age and they are responsible for considerable morbidity and mortality. The relation between theses 2 diseases has long been discussed and determined by clinical studies. Left ventricular hypertrophy and left atrial remodeling during hypertension favor the development of atrial fibrillation. AF during hypertension increases the risk of thromboembolic complications and heart failure. In patients with hypertension, pharmacological treatment may control the cardiac structural changes and retard or prevent the occurrence of atrial fibrillation. In case of atrial fibrillation, treatment should be focused on the control of heart rate and rhythm and the prevention of thromboembolic accidents. A strict control of blood pressure is highly required in this situation.

Attempted suicide by Flécainide overdose: A case report

Class Ic antiarrythmic overdose is associated with a relatively high mortality. We presenta case report regarding a suicidal intoxication of an 18-year old female with a medical history of Wolff-Parkinson-White syndrome. The preliminary examination highlighted a profound cardiovascular collapse. The electrocardiogram showed a PR interval extended to 360 ms. The QRS complexes were enlarged to 360 ms with a right bundle brunch block appearance associated with left posterior hemibloc. There were repolarization abnormalities such as elevation of the J-point, convex ST segment and biphasic T wave in the right precordial leads ("Brugada-Like ECG pattern"). Sodium bicarbonate was administered. A rapid decrease in the duration of the QRS complexes was noted as well as a slowing of the heart rate. The electrocardiogram aspect on the 4th day showed the reappearance of the ventricular pre-excitation. The severity and lethal potential of Flecainide poisoning are linked to the cardiotoxic effects of these molecules. The prognosis remains poor despite progress in intensive care procedures.

Diagnostic value of the bronchoalveolar lavage in interstitial lung disease

Background The bronchoalveolar lavage (BAL) cellular analysis is an invasive method of exploration of the lung. Its diagnostic value in interstitial lung disease (ILD) is integrated to a multi-disciplianry approach implicating clinicians, radiologists and pathologists. Aim We targeted to evaluate the diagnostic value of the BAL. Methods We reported a retrospective study about patients hospitalized for an ILD since the 1st January 2011 to the 31th December 2013. Thirty three patients were admitted in the Department of Pulmonology and the BAL analyses were studied in the Department of Pathology of the same hospital. The different cell patterns were compared to the final diagnostics. Results our study contained 4 non specific interstitial pneumonia (NSIP), 10 usual interstitial pneumoniae (UIP), 4 organizing pneumoniae (COP), 8 sarcoidosis, 2 hypersensitivity pneumonitis, 3 infectious pneumonitis, 1 lymphoma and a pulmonary adenocarcinoma. We considered positive results those that were compatible with the final diagnosis. The profile lavage was typical in 1 NSIP, 3 UIP, 3 COP, 1 hypersensitivity pneumonitis, 6 sarcoidosis, 3 infectious pneumonitis and 1 adenocarcinoma. Among the 17 cases with an atypical profile lavage, radiological features were diagnostic in 10 cases. This finding highlights the fact that 7 cases/ 33 presented simultaneously an atypical profile lavage and non specific radiological findings Conclusion Our results put emphasis on the diagnostic value of BAL especially when it is integrated to a multi-disciplinary approach. Its value in the follow up, the evaluation of the activity of the disease and the prognosis is being more and more reported.