RHYTHM 2013

Arrhythmias & Heart Failure:

New Insights & Technological Advances

Palais du Pharo, Marseille, France

May 31 - June 1, 2013 Directors of the congress Patrick Attuel,

CMC Parly II, Le Chesnay, France

Claude Barnay,

CH du Pays d’Aix, Aix-en-Provence, France

Fiorenzo Gaita,

Università degli Studi di Torino, Turin, Italy

Jean-François Leclercq, CMC Parly II, Le Chesnay, France

André Pisapia,

St Joseph Hospital, Marseille, France

European CME Accreditation

ABSTRACTS

www.rhythmcongress.com

Abstracts of the conferences Friday May 31

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ATRIAL FIBRILLATION, FROM SIGNAL TO IMAGING Deciphering body surface data reveals moving rotors during AFib 08:40 ď Ž RĂŠmi Dubois Pessac, France

Friday May 31

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Recent developments in body surface mapping and computer processing have allowed non-invasive mapping of atrial activation responsible for various cardiac arrhythmias with increasingly greater resolution. We developed specific algorithms to identify localized sources and atrial propagation occurring simultaneously during ongoing atrial fibrillation (AF).

After acquiring the heart-torso relational geometry from scanner tomography (CT scan), segmentation of the three dimensional geometry of the heart diastolic volume is performed. The inverse problem is then computed to get the corresponding cardiac epicardial electric potentials (EcView CardioInsight, Cleveland OH, USA).

Such panoramic mapping adds valuable information on the myocardium condition, and propagating patterns.

Nevertheless, computation on the reconstructed potential is necessary to obtain relevant components of the signals and to exhibit the characteristic mechanisms of the AF. An efficient way, that will be presented here, uses a reconstructed phase signal that gives access to activation fronts, rotors and abnormal automaticity. Spatiotemporal analysis of the rotor locations and trajectories results in composite maps that identify the locations of abnormality and potential targets for ablation procedure.

ATRIAL FIBRILLATION, FROM SIGNAL TO IMAGING Contribution of gap junction channels in atrial fibrillation: a cellular approach 09:00 ď Ž T homas Desplantez IHU LIRYC, Inserm U1045, Bordeaux, France

Atrial fibrillation is the most common sustained cardiac arrhythmia, for which altered cellular mechanisms can be of several sources. Understand these cellular mechanisms is critical, which include the role of gap junctions that ensure a direct electrical cell to cell communication and regulate the action potential propagation. Atrial myocytes co-express three connexins (Cx), the proteins forming the gap junction channels, Cx43, Cx40 and Cx45. On primary cultures we observed distinct junctional densities of atrial connexins that ensure a specific electrical coupling characterized by nearly rectifying voltage dependence. Such behavior is the result of the formation of 75% of channels of mixed connexin composition that promote a unidirectional AP propagation.

Transgenic KOCx43 animals reveal altered electrical properties of gap junction channels (loss of rectifying behavior, change of gap junction channel composition) and a reduced sodium current density by ≈50%, which decreases the conduction velocity indicative of a pro-arrhythmic behavior. This indicates a close regulation of Cx junctional density and sodium channel by Cx43. Our cellular approach consists in using the atrial cell line HL1 and transfected rat liver epithelial cell models that permit the control of the type and ratio of co-expressed connexins. Double patch clamp on cell pairs and microelectrode arrays recordings on cell monolayer by using the cell models expressing various connexins patterns and in isolated heart are performed. Our preliminary data on cell pairs indicate that distinct patterns of connexin expression promote distinct electrical coupling and properties. Microelectrode arrays recordings on HL1 cells and isolated heart under the sinus rhythm and after triggering fibrillation will complement such observations. These recordings will bring a full understanding of the role of the distinctive patterns of connexin co-expression in the healthy heart and in altered co-expression patterns in disease.

Friday May 31

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ATRIAL FIBRILLATION, FROM SIGNAL TO IMAGING Video: Mediguide, the medical GPS in practice for AFib ablation and CRT application 10:45  Massimo Saviano Cotignola, Italy

Friday May 31

6

Interventional cardio-vascular procedures are the main ionizing radiation exposing fields. The possible damages on operators and patients’ health may be classified as stochastic and deterministic.

Deterministic effects are cell killing and modification, such as skin burns, infertility, bone marrow depression, hairs depletion, cataracts and retinal macula degeneration. For this kind of damage, a threshold has been identified in 1Gy. Stochastic effects mainly consist in increased neoplasms induction. What kind of mathematical correlation between radiological exposure and health effect exists and if a threshold can be established. Probably on this background, operators must have ethical concerns on radiation dose reduction or elimination for medical practice. Technological improvement is oriented in this direction as well as in workflow optimization. Good clinical and technical practice strongly reduces x-rays delivery to patients and operators. The creation of nonfluoroscopic mapping systems reduced radiation exposure and improved outcomes for ablation procedures in Cardiac Electrophysiology (EP). A big EP company made a further step in the same direction proposing a new system of real-time catheter localization and visualization. Mediguide gMPS TM is a magnetic field based GPS for medical devices. Catheters, guiding-wires and delivery systems equipped with sub-millimetric sensor are visualized on pre-acquired fluoro images or fluoro loops. Positional markers can be placed navigating the sensor on the target structures. Mediguide records the position in all the acquired projection, creating a 3D orientation system and gates the position on the ECG tracings making possible a virtual temporal position rendering. Fluoroscopic images are no longer necessary after images acquisition. The merging with Ensite Velocity improves the 3D mapping system performance integrating magnetic and electrical fields information.

The unified processing of these data overcomes the previous technical limitations deriving from patient characteristics and fields’ properties.

ATRIAL FIBRILLATION, FROM SIGNAL TO IMAGING Mechanisms of persistent AFib: do rotors have a Role? No. 11:00  Maurits Allessie Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, The Netherlands

The precise mechanisms responsible for the perpetuation of atrial fibrillation are still unknown. Electrical remodeling during the first days of AF (shortening of atrial refractoriness) increases the stability of AF. However, structural atrial remodeling seems to be more important for the development of a substrate of longstanding persistent AF. Progressive changes in the architecture and structure of the atria occur as a result of ageing and various cardiovascular diseases like hypertension, valvular dysfunction, ischemia and heart failure. Also atrial fibrillation itself leads to important changes in the atrial myocardium and extracellular matrix.

In an attempt to elucidate the substrate of longstanding AF, we performed epicardial high density mapping of the right and left atria in 24 patients undergoing mitral valve surgery. A new mapping algorithm was developed that separates the complex fibrillatory process into its individual wavelets (wave-mapping). The total data base consisted of more than 4000 fibrillation maps, recorded from the free wall of the right and left atria and the left posterior wall (PV-area). In all these maps we failed to find a single epicardial reentrant circuit or rotor. Instead, the substrate of AF was characterized by a high degree of electrical dissociation of neighboring muscle bundles and a high incidence of epicardial breakthroughs. In patients with persistent AF, the total length of lines of intra-atrial block was more than 6-fold higher than during acutely induced AF, with a more than 4-fold increase in epicardial breakthroughs. As a result, the fibrillation waves had become very narrow and therefore much more numerous than during acute AF. The width of the fibrillation waves was correlated with the underlying architecture of the atrial wall and varied from 3-6 mm in the right atrium (thick pectinate muscles) to as narrow as 1-2 mm in the area between the pulmonary veins.

We hypothesize that, due to this progressive process of longitudinal and endo-epicardial dissociation, the atria are being transformed into a double layer of electrically dissociated muscle bundles. Instead of reentrant or focal activity, the frequent ‘cross-overs’ of fibrillation waves between these endo- and epicardial layers, occurring over the entire atrial wall (right and left atria alike), now provide a constant source of ‘new’ fibrillation waves. This ‘Double Layer Hypothesis’ offers an alternative explanation for the perpetuation of AF in patients with structural heart disease, without the need for any rotor activity.

Friday May 31

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CLINICAL APPROACH TO TREAT ATRIAL FIBRILLATION Video: Faster PV isolation using cryotherapy 13:50  Franck Halimi Hôpital Privé Parly 2, Le Chesnay, France

Cryoballoon therapy has become a new standard to achieve pulmonary vein isolation for paroxysmal atrial fibrillation. This presentation will focus on recent improvements provided by the new Arctic Front Advance Cryoballoon, the Achieve Mapping Catheter as well as the FlexCath Advance steerable sheath. Technical considerations will be underlined by a video case realized in our centre.

Friday May 31

Video: F aster PV isolation using multi-electrode ablation catheter PVAC Pulmonary vein isolation using the pulmonary vein ablation catheter combined with phased RF energy appears to be an effective technology. This presentation will underline recent innovations with the release of the new PVAC Gold associated with the upgraded GENius Generator with ContactIQ. The new PVAC Gold provides more safety and efficacy and is currently under final evaluation.

Video: Faster PV isolation using nMarq The nMarQ system is the only multi-ablation technology combining irrigation and 3D navigation using the CARTO 3 system. The nMarQ Circular Catheter is steerable and designed with a helical and adjustable loop diameter ranging from 20 to 35 mm. The ten electrodes are irrigated, monitored by their own thermocouple and driven by an independent generator included in the new nMarQ multi-channel RF system. This presentation will be illustrated with a video case shot in our centre.

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Abstracts of the conferences Saturday June1

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TECHNICAL DEVICES’ INNOVATIONS Renal Denervation: its impact on arrhythmias 10:45 ď Ž Dominik Linz Hamburg, Germany

Saturday

June 1

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Increased sympathetic drive together with autonomic imbalance plays an important role for the initiation and perpetuation of atrial fibrillation (AF). Additionally, AF itself as well as other pathophysiological conditions like congestive heart failure, hypertension or obstructive sleep apnea lead to increased sympathetic activation and atrial autonomic remodelling characterized by sympathetic hyperinnervation. Renal sympathetic denervation (RDN) decreases sympathetic renal efferent and afferent nerve activity, leading to decreased central sympathetic drive. Modulation of sympathetic nervous system by RDN significantly reduced increased AF-susceptibility and AF-duration by inhibiting intraapneic shortening of atrial refractoriness in a pig model for obstructive sleep apnea. Importantly, clinically used antiarrhythmic drugs like amiodarone or sotalol displayed a considerably less pronounced antiarrhythmic effect compared to RDN in the same pig model. Additionally, RDN reduced duration of AF without influencing AF-induced electrical remodeling and displayed ventricular rate control in a pig model with rapid atrial pacing. In a small study in humans RDN combined with circumferential pulmonary vein isolation reduced recurrence rate of AF compared to pulmonary vein isolation alone. Blood pressure reduction by RDN was associated with a regression of left ventricular hypertrophy, improved glucose metabolism and obstructive sleep apnea severity, which might attenuate the development of an arrhythmogenic substrate in the atrium.

Besides these atrial antiarrhythmic effects, a first in man report has shown reduced ventricular tachyarrhythmias in two patients with electrical storm and congestive heart failure. In pigs with ventricular ischemia/reperfusion, RDN significantly inhibited premature ventricular extrabeats and reduced the occurrence of ventricular fibrillation during the ischemic phase, while reperfusion arrhythmias were not influenced.

Modulation of sympathetic nervous system by RDN showed pronounced atrial and ventricular antiarrhythmic effects in animal models and human. Whether RDN can reduce ventricular or atrial arrhythmias in different clinical settings deserves controlled clinical trials.

ANTITHROMBOTIC TREATMENTS OF AFIB New oral Anticoagulants (NOACs) 11:20 ď Ž Jean Yves Le Heuzey Georges Pompidou Hospital, RenĂŠ Descartes University, Paris, France

The management of thromboembolic risk in atrial fibrillation patients is, nowadays, completely changing since the arrival on the market of new oral anticoagulants. Last trials have demonstrated at least a non inferiority of these compounds as compared to warfarine: RE-LY for Dabigatran, ROCKET AF for Rivaroxaban and ARISTOTLE for Apixaban. The main interest of these drugs is the lack of monitoring necessity in routine, and the decrease in the occurrence of intracranial bleeding. Dabigatran and Apixaban are prescribed BID, Rivaroxaban OD. The key point for a safe prescription is to control renal function using the measurement of creatinine clearance with Cockroft method. Haemorrhages occurrence is increased if the renal function is impaired. The limitations of these drugs are mainly the absence of specific antidotes and the higher cost as compared to warfarine.

Saturday

June 1

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S ESSION FRANCOPHONE TRANS-MÉDITERRANÉENNE Etat de l’ablation par radiofréquence en Tunisie 14:45  R afik Chettaoui Tunis, Tunisia

Saturday

June 1

L’électrophysiologie et les techniques ablatives ont révolutionnés en Tunisie comme dans tous les pays au monde la prise en charge des troubles des rythmes cardiaques La Première Ablation par radiofréquence a été effectué en 1999 dans un centre hospitalo-universitaire et depuis cette date le nombre de procédures n’a pas cessé d’augmenter.

Actuellement en compte dans le pays 3 centres hospitaliers à Tunis, Sfax et Sousse et 5 centres dans des cliniques privés dont 4 à Tunis et 1 à Sfax qui dispose d’un plateau technique permettant de réaliser les procédures..

Notre système de couverture sociale rembourse à 100% les procédures conventionnelles et à 70% les procédures complexes.

La part la plus importante des procédures est représentée par L’ablation conventionnelles (sans système de cartographie) avec 90,8% des procédures avec des taux de succès immédiat de 93% et un taux de complication immédiat à 1,5% avec un taux de récidive à 20% représentée essentiellement par les réentrées intra nodales et les voies accessoires antéro-septales.

Les Procédures complexes incluant les ablations de fibrillation auriculaire ont commencé en 2008 et comptent actuellement une centaine de procédure à l’année avec un taux de succès avoisinant 70% le nombre de procédure complexes est en augmentation.

Actuellement certains centres on acquis leur autonomie avec un plateau technique et des compétences qui leur permettent de faire face aux problèmes ryhmologiques les plus courants.

Radiofrequency ablation in Tunisia state of the Art Electrophysiology and radiofrequency ablation have dramatically changed our way of managing tachycardia in Tunisia , like in all other countries this technique has evolved.

In 1999 the first procedure was performed in a University Hospital and since this date the number of procedures has increased.

In our country we have 3 university centres; in Tunis, Sfax and Sousse and 4 centres in private hospitals with 4 in Tunis and 1 in Sfax all these centres afford technical support and competences to perform radiofrequency ablation.

Our National Health care system affords total reimbursement for conventional procedures and 70% reimbursement for complex procedures (Using 3D mapping technic ).

Conventional procedures represent 90,8% with 93% success rate , 1,5% immediate complications and 20% of recurrence and most of them are antero-septal accessory pathways and nodal re-entry tachycardia.

In 2008 the first complex procedure using a 3D mapping system was performed, 100 procedures per year are performed using this system in 2 centres in the country including atrial fibrillation ablation and this rate in increasing. The success rate in complex procedures is 70%.

Radiofrequency ablation is routinely performed in our country since 1999 and common and complexes tachycardias are cured in the majority of circumstances.

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Saturday

June 1

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Abstracts PARAMEDICAL er Samedi 1 juin

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LES TROUBLES DU RYTHME. Les tachycardies : rappels & ECG types 09:10  Jérôme Taieb, Annick Bourdeloie CH Aix-en-Provence, France

Les tachycardies sont des accélérations du rythme ventriculaire cardiaque.

Celle ci peut avoir une origine ventriculaire ou beaucoup plus fréquemment supraventriculaire. Dans ce dernier cas, ce sont les oreillettes qui ont une fréquence accélérée et les ventricules suivent cette accélération plus ou moins vite en fonction du filtrage produit par le nœud auriculoventriculaire (NAV).

Samedi

1er juin

1. Tachycardie supraventriculaire : - La plus fréquente est la fibrillation atriale: Les oreillettes ont une dépolarisation anarchique et n’ont plus d’activité contractile ce qui explique l’augmentation du risque thrombotique. L’ECG montre une irrégularité des cycles ventriculaires et on peut distinguer au mieux sur la dérivation V1 une activité auriculaire rapide et anarchique entre les QRS. Ils sont mieux vus à l’occasion d’un cycle long.

- Le flutter auriculaire et une macroreentrée auriculaire facilement identifiable sur l’ECG avec des ondes F de Flutter en «toit d’usine» ou «dent de scie». Ces ondes F peuvent être difficiles à individualiser lors d’une conduction 2/1 si la repolarisation ventriculaire se fond avec ces ondes F. Une manœuvre vagale (massage sino carotidien, injection d’ATP), peut les faire apparaitre. Le flutter auriculaire commun a la particularité de passer dans l’isthme cavotricuspidien accessible à une ablation par abord veineux fémoral. Cette ablation est l’ablation la plus fréquemment pratiquée y compris en première intention en raison de son rapport bénéfice risque très favorable.

- Les tachycardies jonctionnelles (TJ) accélèrent le ventricule par un phénomène de réentrée ( « court circuit»).

La descente se fait par le NAV et la remontée se fait soit par une deuxième voie dans le NAV soit par un faisceau accessoire. Ainsi le blocage du NAV interrompt les conditions du court-circuit et arrête la tachycardie.

De façon atypique le circuit peut être inversé mais le NAV sera de toute façon un passage obligé et susceptible d’interrompre la tachycardie en cas de blocage. L’ablation de la voie «lente» pour laisser la voie rapide est la technique de choix pour les réentrées intra nodales. L’ablation de la voie accessoire est également proposée en cas de TJ par ce mécanisme. Ces ablations sont généralement proposées plutôt après échec des antiarythmique ou en cas d’intolérance ou de désir d’éviter une prise médicamenteuse.

2. Les tachycardies ventriculaires (TV) Les ventricules sont plus nombreux que les oreillettes. Cette dissociation n’est pas toujours facile à voir car les QRS rapides ne laissent pas de place pour voir les déflexions atriales.

Il s’agit d’un court-circuit (macro réentrée) sur cicatrice ou d’un foyer ectopique.

Les TV cicatricielles (post infarctus, CMD, DVDA…) sont les plus fréquentes. Les TV focales sont plus rares et moins à risque de dégénérer en fibrillation ventriculaire qui est la complication la plus redoutée des TV. Seules les premières relèvent en l’absence de cause réversible de l’implantation d’un DAI. Toutes les TV sont accessibles à l’ablation.

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ECHANGES DE PRATIQUES. GESTION OPÉRATOIRE ET PÉRI-OPÉRATOIRE : COMPLICATIONS, TRAITEMENTS… Gestion infirmière péri-opératoire au cours des ablations simples 10:45  Anne-Marie Simoni, Françoise Kopp CH Aix-en-Provence, France

L’ablation non complexe concerne l’ablation des Flutter auriculaire commun, Tachycardie jonctionnelle, et Nœud AV Phase pré-opératoire • Organisation procédure : plage opératoire réservée dans logiciel de RDV, réservation lit, rappel téléphonique du patient la semaine précédent l’intervention.

• La veille en service : accueil et préparation du patient, remise du formulaire de consentement (à signer), douche bétadinée, ECG, bilan sanguin. Réservation d’un lit au SIC. Programmation dans logiciel du transport interne aller-retour bloc.

• Jour du Bloc, rasage en short, antalgique 1H avant, vérification du jeûne… validé dans le formulaire «Protocole de liaison cardio bloc opératoire»

Samedi

1er juin

Phase opératoire • Ouverture de salle (vérification défibrillateur, O2, masque, ambu, aspiration, chariot d’urgence) et préparation matériel (générateur, stimulateur…) .

• Accueil du patient et explications • Contrôle du formulaire «Protocole de liaison cardio bloc opératoire» • Installation du patient (monitorage ECG, SPO2, TA, patchs défibrillation, électrodes indifférentes).

• Préparation du champ opératoire betadiné..

• Installation espace stérile (champ patient/table) • Sédation légère IV fréquente • Le médecin fait une anesthésie locale et plusieurs ponctions veine fémorale droite et met en place des sondes • Surveillance clinique et scope : possible malaises vagaux pendant ponction.

• L’IDE règle les paramètres du générateur. Parfois l’ablation est «irriguée» nécessitant une perfusion de la sonde via une pompe.

• En fin de procédure, retrait des sondes et pansement très compressif • Retour au SIC • Consignes médicales transmises depuis le bloc ( impression à distance) • Alitement strict 12 H sans plier la jambe • Retrait du pansement le lendemain Complications à rechercher Hématome du scarpa Douleur thoracique transitoire Arythmies Epanchement péricardique ou thoracique nécessitant une évacuation en urgence (Kit péricardique au bloc et au SIC) Accident thromboembolique

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ECHANGES DE PRATIQUES. GESTION OPÉRATOIRE ET PÉRI-OPÉRATOIRE : COMPLICATIONS, TRAITEMENTS… Gestion infirmière péri-opératoire des ablations complexes 11:05  F rancine Quervelle, Pauline Buiguez, Fiona Ducrot, Nathalie Leborgne, Benoit Maruejouls

Samedi

1er juin

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Le sujet que nous présenterons est la gestion IDE péri opératoire des ablations complexes.

Elles concernent la FA, le flutter gauche, les TV, et les interventions sur les patients très jeunes ou porteurs de cardiopathie congénitale.

Lors des trois dernières années nous avons enregistré 35% d’ablation complexe sur l’ensemble de l’activité du service. Nous obtenons ce taux grâce aux urgences spécialisées en cardiologie dans notre établissement ainsi qu’à la relation et la proximité que nous entretenons avec l’hôpital pédiatrique de la Timone.

D’autre part, la diversité des pathologies, les antécédents et de la provenance des patients va modifier notre approche paramédicale et psychologique de ceux-ci et de leurs entourages.

Notre travail met en exergue les différences de prise en charge entre les ablations simples et complexes.

Celles-ci portent essentiellement sur la préparation du patient : Dans un premier temps, le contrôle pré-ablation de paramètres notamment biologiques qui permettront de limiter les risques du geste.

Puis, le préparer aux risques accrus de l’intervention dut à la de multiplication des voies et de la procédure. (Par exemple groupage sanguin pour palier au risque hémorragique) Et enfin de la préparation psychologique du patient qui doit insister sur la durée de l’examen, ses risques, replacer l’ablation dans le contexte de la pathologie et souligner le fait qu’elle ne sera pas nécessairement complètement curative et que plusieurs procédures pourront être nécessaires.

Nous décrirons les examens requis, le maniement des anticoagulants et les protocoles du service.

Nous exposerons un court paragraphe sur les pratiques au bloc opératoire car il est primordial de les connaître afin d’optimiser les soins péri opératoires et de renseigner le patient sur ce qui l’attend.

La surveillance postopératoire nécessite une vigilance accrue que nous décrirons.

En effet, les complications qui peuvent survenir sont plus sévères.

Finalement, après l’intervention, la plupart des patients sortent avec un traitement anticoagulant et/ou anti arythmique à long terme.

Ils doivent continuer à avoir un suivi régulier avec leur cardiologue tout au long de leurs vies. Ceci est une différence majeure avec le devenir des patients ayant une ablation simple.

ECHANGES DE PRATIQUES. GESTION OPÉRATOIRE ET PÉRI-OPÉRATOIRE : COMPLICATIONS, TRAITEMENTS… Bloc opératoire : Ablation de Flutter gauche et cartographie : une «complication» classique de l’ablation de FA 11:55  Patrick Lafond, Philippe Ricci CH St Etienne, France

L’ablation de la fibrillation atriale se multiplie dans les centres experts. Si le traitement par radiofréquence de ce trouble rythmique remporte un franc succès, elle n’en reste pas moins responsable du développement d’arythmies complexes de l’oreillette gauche. De 1 à 15% selon la stratégie d’ablation adoptée précédemment.

Leurs diagnostics et leurs traitements n’étant pas toujours évidents, il devient alors indispensable de s’aider de technologies supplémentaires faisant appel entre autres au système de cartographie.

Samedi

1er juin

19

EVOLUTION DU MATÉRIEL : GESTION DES RISQUES ET AVANCÉES TECHNOLOGIQUES POUR LE PATIENT Cas matériovigilance : Défaillance de sonde : gestion et suivi de 219 patients de 2007 à 2013 14:30  B ernard Samuel, Isabelle Martel CH St Etienne, France

Samedi

1er juin

20

En 2007, dans le cadre de suivi des défibrillateurs implantable, Medtronic lance un avis d’alerte sur un type d’électrode, rapidement suivi par des recommandations de l’AFSSAPS. Prise en charge de cette matériovigilance de grande échelle tant sur le plan : - législatif - médical - et humain.

EVOLUTION DU MATÉRIEL : GESTION DES RISQUES ET AVANCÉES TECHNOLOGIQUES POUR LE PATIENT Les matériels du futur Télécardiologie : développement en France et évolution de la règlementation 16:30  Eric Peyrouse 1, Xavier Laroche 2 1. Hôpital de la Timone, Marseille, France 2. Biotronik, France

Avec plus de 10 ans de recul, le suivi à distance pour les prothèses cardiaques implantables a passé la phase d’expérimentation et de validation pour entrer dans la pratique clinique. L’utilisation des technologies sans fil et d’Internet permet aux industriels de développer des systèmes simples et discrets qui se placent au domicile du patient pour prolonger son suivi en dehors de ses visites de contrôle. Si les constructeurs ont fait des choix différents, tous permettent à minima un contrôle périodique de la prothèse, et la détection d’événements afin de prendre en charge au plus tôt des problèmes techniques ou rythmiques. Les études ont montré la sécurité du suivi à distance comme alternative au suivi classique, et indiquent des bénéfices pour la fibrillation atriale et les AVC associés, et la réduction des chocs inappropriés des défibrillateurs. Il reste maintenant de grandes attentes concernant l’insuffisance cardiaque, pour la prévention des épisodes de décompensation cardiaque et la réduction des hospitalisations. Du côté réglementaire, les choses avancent depuis la loi relative à l’Assurance Maladie de 2004 qui mentionnait pour la première fois la télémédecine. La Haute Autorité de Santé (HAS) s’est prononcée sur le service médical rendu par la télécardiologie, ce qui a donné lieu à une valorisation des systèmes qui permet leur diffusion. Le cadre légal de la télémédecine a été précisé par un décret d’application de la loi Hôpital, Patients, Santé et Territoire qui en définit les différents champs. La généralisation de la télécardiologie passe maintenant par une valorisation de l’acte médical qui permettra aux professionnels et aux établissements de santé de s’organiser. De nouveaux modèle d’organisation et de financement restent à inventer, l’une des clés étant la délégation des tâches a des paramédicaux.

Samedi

1er juin

21

Abstracts FREE PAPERS Saturday June1

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ATRIAL FIBRILLATION (ABLATION) Ganglionated Plexi Ablation Directed by HighFrequency Stimulation And Complex Fractionated Atrial Electrograms for Paroxysmal Atrial Fibrillation 16:00 ď Ž Artem Strelnikov Doctor, Novosibirsk State Research Institute of Circulation Pathology, Arrhythmias Department, Novosibirsk, Russia Co-authors: Denis Losik, Sevda Bayramova, Evgeny Pokushalov, MD, PhD, Alexander Romanov,

MD, PhD, Sergey Artyomenko, MD, PhD, Natalia Shirokova, MD, PhD, Alexey Turov, MD, PhD, Alexander Karaskov, MD, PhD

Saturday

June 1

Introduction The effectiveness of ganglionated plexi (GP) ablation in patients with AF is ambiguous. Some researchers had already suggested that additional identification of complex fractionated atrial electrograms (CFAE) around the areas with a positive reaction to high-frequency stimulation (HFS) might improve the accuracy of GPs boundaries location, then enhancing the success rate of ablation. The purpose of this study was to assess the safety and efficacy of GP ablation directed by HFS and CFAE in patients with paroxysmal AF (PAF).

Methods and Results Sixty-two patients with paroxysmal AF (age 57Âą8 years) underwent ganglionated plexi (GP) ablation. Ablation targets were the sites where vagal reflexes were evoked by HFS and additional extended ablation CFAE area around the areas where vagal reflexes were evoked. At 12 months, 71% of patients were free of symptomatic AF. At 3 months after ablation the rMSSD and HF were significantly lower in patients without AF recurrence (p<0.0001 and p=0.004). The LF/HF ratio was significantly higher in patients without AF recurrence (p=0.02).

Conclusions Enhanced GP ablation directed by high-frequency stimulation and complex fractionated atrial electrograms can be safely performed and enables maintenance of sinus rhythm in majority of patients with PAF for a 12-month period. Denervation of the intrinsic cardiac autonomic nervous system may be the preferable target of catheter ablation of atrial fibrillation.

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ATRIAL FIBRILLATION (ABLATION) Benefit Of Ablation Of First Diagnosed Atrial Fibrillation In Patients Submitted To Coronary Artery Bypass Grafting 16:06  Artem Strelnikov Doctor, Novosibirsk State Research Institute of Circulation Pathology, Arrhythmias Department, Novosibirsk, Russia Co-authors: Denis Losik, Sevda Bayramova, Evgeny Pokushalov, MD, PhD, Alexander Romanov,

MD, PhD, Alexander Chernyavskiy, MD, PhD, Alexander Karaskov, MD, PhD Introduction In patients with long-term history of paroxysmal atrial fibrillation (AF) a decision can be made to go for concomitant coronary artery bypass grafting (CABG) and epicardial AF ablation procedures. Whether patients with recent onset of PAF might benefit of epicardial AF ablation concomitant to CABG is not known. Aim of this prospective, randomized, single-center pilot study is the comparison of patients with first diagnosed AF submitted to CABG and treated with and without epicardial pulmonary vein isolation (PVI).

Saturday

June 1

Methods Patients with first diagnosed paroxysmal AF and indication for CABG were enrolled in this prospective randomized pilot study. The primary endpoint was AF free survival (AF burden <0.5%) between two groups at 18 months follow up. The secondary end-points were: the percentage of AF burden defined through continuous monitoring using an implantable loop recorder, thromboembolic events and procedural complications. All patients were implanted with a subcutaneous cardiac monitor to track the cardiac rhythm and measure the AF burden.

Results This study enrolled 43 patients (mean age 59±7 years, 74% males), followed up for 18 months after CABG. The patients were randomly allocated to two groups, CABG alone (n=21) and CABG with concomitant PVI (n=22). At the 18- month follow-up after surgery, 19 (86%) patients in the CABG+PVI group were AF-free (i.e.

AF%<0.5%) vs 9 (43%) in the CABG only group (Log-Rank test, p=0.007). At the end of follow-up, the mean AF burden in the CABG and CABG+PVI group was 7.8±5.1% and 1.6±1.8%, respectively (P<0.001). Four (26%) of the 15 patients with AF recurrences were completely asymptomatic.

Conclusions Patients with recent-onset atrial fibrillation submitted to CABG may benefit of concomitant ablation of the arrhythmia for preventing recurrences.

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ATRIAL FIBRILLATION (CONTINUOUS MONITORING) Does AF Burden Measured By Implantable Loop Recorder During Post-ablation Blanking Period Predict Response At 12 Month Follow-up?

16:12 ď Ž Denis Losik Cardiologist, Arrhythmia Department and EP Laboratory, Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russia Co-authors: Artem Strelnikov, Sevda Bayramova, Evgeny Pokushalov, Alexander Romanov,

Sergey Artyomenko, Alexey Turov, Natalia Shirokova, Alexander Karaskov

Saturday

June 1

Introduction The aim of this study was to identify if there is a threshold of AF burden during the first months post-ablation obtained through continuous subcutaneous monitoring that can identify patients at risk of subsequent AF recurrences.

Methods 613 patients with symptomatic drug refractory AF (17% with persistent AF) were enrolled in this retrospective analysis. All patients underwent circumferential pulmunary vein isolation (PVI) and were implanted with an ILR for collecting data on AF burden during 12-month follow-up. AF freedom (Responders) was defined as AF%<0.5% during follow-up period. A ROC curve analysis was performed to identify the value of AF burden during the first 2 months post ablation (Blanking Period, BP) that was predictive of late recurrence of AF. Results After the first ablation procedure, 396 (65%) of the 613 patients were AF-free at 12-month: 346 out of 508 (68%) in the paroxysmal AF group and 50 out of 105 (47%) in the persistent AF group.

Using the ROC curve (Fig 1), the specificity corresponding to 90% sensitivity was 75%. The corresponding threshold in the AF burden during the blanking period able to identify patients at risk of late recurrences was 7.1%, corresponding to 102h (= 4.25 days) in AF during the 2 months BP. At the multivariate analysis, a threshold in the AF burden <7.1% during BP was still highly significant (p<0.0001) and the odds of responders/ non-responders was 21.5 (10.8 - 42.9).

Conclusions The BP AF pattern predicted response to catheter ablation. An AF burden â&#x2030;Ľ7.1% assessed by continuous monitoring was a powerful predictor of subsequent AF recurrence after initial ablation, and thus be an appropriate guide for early re-intervention.

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ATRIAL FIBRILLATION (ABLATION) Ablation of Paroxysmal and Persistent Atrial Fibrillation: Long-term Recurrence Rates Via Continuous Subcutaneous Monitoring 16:18 ď Ž Sevda Bayramova Cardiologist, Arrhythmia Department and EP Laboratory, Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russia Co-authors: Artem Strelnikov, Denis Losik, Evgeny Pokushalov, Alexander Romanov,

Sergey Artyomenko, Alexey Turov, Natalia Shirokova, Alexander Karaskov Introduction Concerns have been raised that over prolonged follow-up, initial responders to ablation of atrial fibrillation (AF) may recur very late post-procedure, even years after. Existing data, however, are limited to symptomatic events or at best, intermittent Holter or event recordings. The aim of this prospective observational study was to comprehensively track recurrence rates over 3 years post-ablation using implantable loop recorders (ILRs).

Saturday

June 1

Methods One hundred twenty nine patients with symptomatic drug refractory AF (45% with persistent AF) were enrolled. All patients underwent circumferential pulmunary vein isolation (PVI) with ILRs inserted for continuous AF monitoring during the 36-month follow-up. AF freedom was defined as AF%<0.5%.

Results Complete PVI was achieved in 100% of cases. With a single procedure at the 12-month follow-up, 76 (59%) of the 129 patients were AF-free: 48 out of 71 (68%) in the paroxysmal AF group and 28 out of 58 (48%) in the persistent AF group. At the 36-month, 43 (33%) of the 129 patients were AF-free: 29 out of 71 (41%) in the paroxysmal AF group and 14 out of 58 (24%) in the persistent AF group.

A 2nd procedure was performed in 41 (32%) and a 3rd in 6 (5%) patients. After the final ablation, 78 (60%) of the 129 patients were AF-free at 36 mos: 56 out of 71 (65%) in the paroxysmal AF group and 32 out of 58 (55%) in the persistent AF group.

In the overall population, the AF% dramatically decreased by 6-months, followed by a plateau and a gradual increase after 16 months. 11 patients (21%) of the non-responders were completely asymptomatic. Progression to longstanding persistent AF was observed in 18 patients (14%).

Conclusions Although ablation is effective in treating AF, there is a signficant attrition rate as assessed through detailed 3-year continuous ILR monitoring. Prior studies underestimated very late recurrences and failed to account for asymptomatic patients. The use of ILRs is a valuable means of identifying responders and non-responders, and can potentially guide therapies.

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ATRIAL FIBRILLATION (ABLATION) Ganglionated Plexi Ablation Combined With Pulmonary Vein Isolation Improves Outcome Of Catheter Ablation In Patients With Longstanding Persistent Atrial Fibrillation: A Prospective Randomized Comparison 16:24 ď Ž Sevda Bayramova

Saturday

June 1

Cardiologist, Arrhythmia Department and EP Laboratory, Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russia Co-authors: Artem Strelnikov, Denis Losik, Evgeny Pokushalov, Alexander Romanov,

Sergey Artyomenko, Alexey Turov, Natalia Shirokova, Alexander Karaskov Introduction Pulmonary vein isolation (PVI) is an established strategy for paroxysmal atrial fibrillation (AF) but seemed to be less effective in patients with persistent AF. Some researchers had already suggested that additional ganglionated plexi (GP) ablation might improve the success rate. The aim of our study was to assess the maintenance of sinus rhythm (SR) in patients with longstanding persistent AF at least 3 years using 2 different ablation strategies, PVI plus linear lesions (LL) versus PVI plus GP ablation.

Methods Two hundred sixty four consecutive patients with longstanding persistent AF were randomly assigned to 2 different ablation schemes: PVI plus LL (n=132) and PVI plus GP ablation (n=132). Primary end point was to assess the maintenance of SR after procedures in a long-term follow-up of at least 3 years.

Results All cases underwent the procedure successfully. PVI was achieved in all cases. With a single procedure at the 12-month follow-up, 47% of patients treated with PVI plus LL were in SR, whereas at the 3-year follow-up, 34% maintained SR; using the PVI plus GP with a single procedure at the 12-month follow-up 54% of patients were in SR (p=0.068), whereas at the 3-year follow-up, 49% remained in SR (p=0.021).

Atrial flutter was more frequent in the group of PVI plus LL than in PVI plus GP ablation group (11% versus 4%, P=0.036). After a second procedure, the long-term overall success rate was 52% with PVI plus LL and 68% with PVI plus GP ablation (p=0.018).

Conclusions The difference between PVI plus LL and PVI plus GP ablation strategy is not statistically significant at 12 months in patients with longstanding persistent AF, whereas the difference becomes statistically significant in the longterm follow-up because of the higher number of recurrences in the PVI plus LL group.

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Crucial areas and cumulative effect of Complex Fractionated Atrial Electrograms ablation on Atrial Fibrillation termination 16:30  A lexandre Maluski, MD, Julien Seitz, MD, Clément Bars, MD, Jérôme Horvilleur, MD, Jérôme Lacotte, MD, Arnaud Rosier, MD, Ange Ferracci, MD, Jacques faure, MD, Michel Bremondy, MD, Laurence Curel, MASc, Guillaume Penaranda, PhD and André Pisapia, MD Saint Joseph Hospital, Marseille, France, Institut Mutualiste Montsouris, paris, France, Institut Hospitalier Jacques Cartier, Massy, France

Introduction Recent data has demonstrated that focal sources are determinant in human Atrial Fibrillation (AF) perpetuation.

We sought to evaluate the cumulative effect of Complex Fractionated Atrial Electrograms (CFAE) ablation on AF Cycle Length (CL) and to identify crucial areas for AF perpetuation.

Saturday

June 1

Methods Patients with refractory AF (n=113, 73% males, 60±10 years, 83% of non paroxysmal) underwent CFAE ablation with AF termination endpoint: conversion to Atrial Tachycardia (AT) or Sinus Rhythm (SR).

Ablation points where classified as “crucial”, when they increased the CL over 20% of initial CL, or terminated AF. For AT organisation, focal or linear ablations were performed according to the mechanism of tachycardia.

Results AF was terminated by defragmentation in 108/ 113 patients (95.6%), with SR conversion by ablation in 87/113 (77%). A cumulative effect of defragmentation with progressive increase of AF CL was observed in 97% (34.9 ± 25.8 ms). We identified 209 crucial points localised into 3 main zones: Mitral Annulus/ periLAA, peri-CS ostium and fossa ovalis areas (figure).

AF was organized in AT in 76 pts, 58 were successfully ablated: 38 macro-circuits (19 peri-tricuspid, 13 perimitral, 6 roofs) and 41 foci (9 CS ostium, 6 LAA ridge, 5 inferior LAA root, 3 antero-superior right PV). Mean procedure and fluoroscopic times were 220± 63 min and 22±14.5 respectively.

Conclusions Although CFAE ablation had a cumulative effect on AF with progressive CL increase, crucial areas on its perpetuation have been identified especially around the CS ostium, fossa ovalis, and Mitral annulus/peri-LAA area.

Author Disclosure Information: A. Maluski: J - Fellowship Support; 1; Sorin Group, Boston Scientific Corp. J. Seitz: A - Consulting Fees/Honoraria; 1; Boehringer Ingelheim. C. Bars: None.

J. Horvilleur: None. J. Lacotte: None.

A. Rosier: None. A. Ferracci: A Consulting Fees/Honoraria; 1; Medtronic, Inc., Sorin Group, St. Jude Medical.

J. Faure: A - Consulting Fees/Honoraria; 1; Medtronic, Inc., Sorin Group, St. Jude Medical. M. Bremondy: A - Consulting Fees/Honoraria; 1; Medtronic, Inc., Sorin Group, St. Jude Medical. L. Curel: None.

G. Penaranda: None. A. Pisapia: A - Consulting Fees/Honoraria; 1; Medtronic, Inc., St. Jude Medical, Sorin Group, Boehringer Ingelheim.

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Effects of Renal Sympathetic Denervation on the Initiation of a Substrate for Atrial Fibrillation in Obstructive Sleep Apnea 16:36  D ominik Linz 1, Mathias Hohl 1, Alexander Nickel 1, Michael Wagner 1, Daniel Urban 1, Sebastian Ewen 1, Ulrich Schotten 2, Christoph Maack 1, Felix Mahfoud 1, Klaus Wirth 3, Michael Böhm 1 1. Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III, Homburg/Saar, Germany 2. Cardiovascular Research Institute Maastricht (CARIM), The Netherlands 3. Sanofi-Aventis Deutschland GmbH, R&D, Aging / Disab. of CVC origin, Frankfurt, Germany

Saturday

June 1

Background Obstructive sleep apnea (OSA) is associated with atrial arrhythmogenic electrophysiological and structural changes. The role of the sympathetic nervous system for creating a substrate for atrial fibrillation (AF) in OSA and the underlying mechanisms are unknown.

Methods and Results Renal sympathetic denervation (RDN) decreases sympathetic renal afferent nerve activity, resulting in decreased central sympathetic efferent outflow. We studied the effects of RDN on atrial electrophysiology, occurrence of spontaneous AF-episodes, neurohumoral activation and initiation of profibrotic pathways in pigs with repetitive obstructive apneas for 4 hours. Repetitive obstructive apneas increased spontaneous AF-episodes, which were triggered by spontaneous atrial beats and maintained by shortened intra-apneic atrial refractoriness. Tracheal occlusions resulted in post-apneic blood pressure rises, increased plasma renin activity and aldosterone concentrations. Atrial expression of mineralocorticoid receptor and atrial tissue aldosterone levels were unchanged, whereas 11-β-hydroxysteroid-dehydrogenase-2 was elevated. This was associated with reduced antioxidative capacity, increased NADPH-oxidase activity and increased expression of connective tissue growth factor. RDN prevented AF triggered by spontaneous premature atrial beats and shortened atrial refractoriness, inhibited post-apneic blood pressure rises, decreased plasma renin activity and aldosterone concentrations.

Increased atrial oxidative stress together with activation of profibrotic pathways and intermittent hypoxia were not attenuated after RDN. Conclusions Repetitive obstructive apneas triggered spontaneous AF, shortened intraapneic atrial refractoriness, increased atrial oxidative stress and activated profibrotic pathways in the atrium. RDN reduces the occurrence of spontaneous AF and post-apneic blood pressure rises. This anti-arrhythmic effect seems independent of a reduction in atrial oxidative stress or subsequent activation of profibrotic pathways.

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Relationship between conventional and contact force-controlled radiofrequency catheter ablation of atrial fibrillation: clinical outcome after 12 months 16:42  Berkowitsch A, Zaltsberg S, Lehinant S, Greiss H, Pajitnev D, Hamm C, Kuniss M, Neumann T. Kerckhoff Heart Center, Bad Nauheim, Germany

Background The clinical efficacy of catheter ablation of atrial fibrillation (AF) remains limited by difficulty in achieving durable pulmonary vein isolation (PVI). Aim of this single-center study was to determine the relationship between conventional and contact force-controlled radiofrequency (RF) catheter ablation for AF regarding clinical outcome after 12 months.

Methods A total of 49 patients who underwent PVI using RF ablation catheter with the possibility of contact forcecontrolled (group 1) ablation (TactiCath™, Endosense, Switzerland or SmartTouch™, BiosenseWebster, USA) were matched to another group of AF patients (n=49) who underwent PVI using a conventional irrigated RF ablation catheter without CF control (group 2). All 98 procedures were first ablation procedures 3 D-mapping guided (Carto III™, BiosenseWebster or NavX™, SJM). PVI defined as ablation endpoint was verified by entrance- and exit block in each PV. Clinical follow-up visit was performed routinely every 3 months, including a 7-day Holter ECG. In case of any palpitations, patients were instructed to obtain an ECG. Primary endpoint was 1st documented recurrence of AF, atrial tachycardia and flutter after a blanking period of 1 month.

Saturday

June 1

Results The majority of both groups presented as non paroxysmal AF (group 1:65% vs. group 2:73%) with a history of AF ≥ 3.0 years. Approximately 75% of pts in both groups had hypertension and 50% metabolic syndrome.

LVEF was normal and left atria were increased in both groups (>22 cm2). The ablation strategy in both groups did not differ: PVI as the ablation endpoint was achieved in all patients by ipsilateral wide area circumferential ablation. In 60% of the patients additional substrate modification was performed (mostly roof line and/or mitral isthmus line). Skin-to-skin procedure time was significantly reduced in group 1 (median 3.5 vs. 4.2 h, p<.006).

Median contact-force during PVI was 19 (17/23) g. Pericardial tamponade occurred in one patient in group 1 during ablation on the posterior wall at the LSPV, interestingly without increase of CF. Regarding the primary endpoint AF free survival was significantly increased in group 1 (73.5%) vs. group 2 (51.0%) with a maximum FU of 12 months (median 8 months).

Conclusions PVI using contact force-controlled RF ablation demonstrates favorable rates of clinical outcome with significant enhancements to key procedural metrics. The contact force information itself does not completely avoid complications like tamponades.

31

Fragmentation in atrial fibrillation as critical fluctuations. In search of connections with rotors.

16:48 ď Ž Guillaume Attuel

Saturday

June 1

32

Strong evidences of critical fluctuations during atrial fibrillation (AF) in humans has been reported, and will be presented.

The conventional picture, which involves spatiotemporal patterns of chaotic spiral waves in excitable media, is therefore incorrect.

Phenomenological analogies with self organized criticality in physical systems, generically referred to as quenched-in disorder magnetic materials, exhibiting jamming and avalanches, designate the network of gap junctions as a crucial facet of AF. Their dynamics indeed allow for alterations of neighboring cell cycles, otherwise in a normal state of their membrane dynamics.

Many of these physical systems present topological defects such as vortices. We will further discuss whether some elements of comprehension of rotors in the heart can relate to such kind of defects.

Percentage of indicated anticoagulation management in patients with chronic atrial fibrillation 16:54 ď Ž K onstantinos Tziomalos, Konstantia Psianou, Aikaterini Konstantakou, Anastasios Hatzopoulos, Martha Apostolopoulou, Alexandra Adamidou, Christos Savopoulos, Apostolos I. Hatzitolios First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece

Background Anticoagulation management of patients with non-valvular atrial fibrillation (AF) depends on the patientsâ&#x20AC;&#x2122; additional risk factors for stroke. Current guidelines recommend the use of the CHADS2 score, which assigns 1 point for the presence of heart failure, hypertension, type 2 diabetes mellitus and age > 75 years and 2 points when there is a history of stroke. Patients with CHADS2 score 0 should receive aspirin, those with score 1 should be given aspirin or warfarin and those with score > 2 should receive warfarin. However, a considerable proportion of patients with AF are not given the appropriate anticoagulation management.

Saturday

June 1

Aim To assess the proportion of patients with AF who are given the recommended anticoagulation management.

Material-Methods The study included 191 consecutive patients with AF (48.7% males, age 76.7Âą8.1 years) who were hospitalized in our Department.

Results The proportion of patients who had CHADS2 score 0, 1 and > 2 was 11.5, 22.0 and 66.5%, respectively. The proportion of patients with CHADS2 score 0, 1 and > 2 who was being given the appropriate anticoagulation management on admission was 13.6, 61.9 and 35.4%, respectively (p = 0.002). Patients who were receiving the recommended anticoagulation management did not differ from patients who were inappropriately managed in gender, age or coexisting cardiovascular diseases. Among patients with CHADS score 0, 1 and > 2, 59.1, 38.1 and 26.8%, respectively, was not receiving any anticoagulation.

Conclusion Only a small proportion of patients with AF are given the appropriate anticoagulation management and this proportion is even lower in patients at the greatest risk for stroke (i.e. with CHADS2 score > 2).The relatively small percentage may reflect also the problems raised by the use of coumarin anticoagulants which are expected to be improved by the wider use of the newer per os anticoagulants.

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