Background: In patients undergoing paroxysmal atrial fibrillation (PAF) ablation, pulmonary vein isolation (PVI) alone fails in maintaining sinus rhythm in up to one third of patients after a first catheter ablation. Epicardial adipose tissue (EAT), as an endocrine-active organ, could play a role in the recurrence of AF after catheter ablation. Objective: To evaluate the predictive value of clinical, echocardiographic, biological parameters and epicardial fat density measured by computed tomography scan (CT-scan) on AF recurrence in PAF patients who underwent a first pulmonary vein isolation procedure using radiofrequency (RF). Methods: This monocentric retrospective study included all patients undergoing first-time RF PAF ablation at the Nancy University Hospital between March 2015 and December 2018 with one-year follow-up. Results: 389 patients were included, of whom 128 (32.9%) had AF recurrence at one-year follow-up. Neither total-EAT volume (88.6 ± 37.2 cm³ vs. 91.4 ± 40.5 cm³, p = 0.519), nor total-EAT radiodensity (−98.8 ± 4.1 HU vs. −98.8 ± 3.8 HU, p = 0.892) and left atrium-EAT radiodensity (−93.7 ± 4.3 HU vs. −93.4 ± 6.0 HU, p = 0.556) were significantly associated with AF recurrence after PAF ablation. In multivariate analysis, previous cavo-tricuspid isthmus (CTI) ablation, ablation procedure duration, BNP and triglyceride levels remained independently associated with AF recurrence after catheter ablation at 12-months follow-up. Conclusion: Contrary to persistent AF, EAT parameters are not associated with AF recurrence after paroxysmal AF ablation. Thus, the role of the metabolic atrial substrate in PAF pathophysiology appears less obvious than in persistent AF.

Prophylactic implantable cardioverter–defibrillators (ICDs) are not recommended until left ventricular ejection fraction (LVEF) has been reassessed 40 to 90 days after an acute myocardial infarction. In the current therapeutic era, the prognosis of sustained ventricular arrhythmias (VAs) occurring during this early post-infarction phase (i.e. within 3 months of hospital discharge) has not yet been specifically evaluated in post-myocardial infarction patients with impaired LVEF. Such was the aim of this retrospective study. Data analysis was based on a nationwide registry of 1032 consecutive patients with LVEF ≤ 35% after acute myocardial infarction who were implanted with an ICD after being prescribed a wearable cardioverter–defibrillator (WCD) for a period of 3 months upon discharge from hospital after the index infarction. ICDs were implanted either because a sustained VA occurred while on WCD (VA+/WCD, n = 72) or because LVEF remained ≤35% at the end of the early post-infarction phase (VA−/WCD, n = 960). The median follow-up was 30.9 months. Sustained VAs occurred within 1 year after ICD implantation in 22.2% and 3.5% of VA+/WCD and VA−/WCD patients, respectively (P < .0001). The adjusted multivariable analysis showed that sustained VAs while on WCD independently predicted recurrence of sustained VAs at 1 year (adjusted hazard ratio [HR] 6.91; 95% confidence interval [CI] 3.73–12.81; P < .0001) and at the end of follow-up (adjusted HR 3.86; 95% CI 2.37–6.30; P < .0001) as well as 1-year mortality (adjusted HR 2.86; 95% CI 1.28–6.39; P = .012). In patients with LVEF ≤ 35%, sustained VA during the early post-infarction phase is predictive of recurrent sustained VAs and 1-year mortality. Overview of the WICD-MI study. ICD, implantable cardioverter–defibrillator; LVEF, left ventricular ejection fraction; MI, myocardial infarction; OMT, optimal medical therapy; TTE, transthoracic echocardiography; VA, ventricular arrhythmia; VF, ventricular fibrillation; VT, ventricular tachycardia; WCD, wearable cardioverter–defibrillator

Aims: Heart transplantation (HT) can be proposed as a therapeutic strategy for patients with severe refractory electrical storm (ES). Data in the literature are scarce and based on case reports. We aimed at determining the characteristics and survival of patients transplanted for refractory ES. Methods and results: Patients registered on HT waiting list during the following days after ES and eventually transplanted, from 2010 to 2021, were retrospectively included in 11 French centres. The primary endpoint was in-hospital mortality. Forty-five patients were included [82% men; 55.0 (47.8–59.3) years old; 42.2% and 26.7% non-ischaemic dilated or ischaemic cardiomyopathies, respectively]. Among them, 42 (93.3%) received amiodarone, 29 received (64.4%) beta blockers, 19 (42.2%) required deep sedation, 22 had (48.9%) mechanical circulatory support, and 9 (20.0%) had radiofrequency catheter ablation. Twenty-two patients (62%) were in cardiogenic shock. Inscription on wait list and transplantation occurred 3.0 (1.0–5.0) days and 9.0 (4.0–14.0) days after ES onset, respectively. After transplantation, 20 patients (44.4%) needed immediate haemodynamic support by extracorporeal membrane oxygenation (ECMO). In-hospital mortality rate was 28.9%. Predictors of in-hospital mortality were serum creatinine/urea levels, need for immediate post-operative ECMO support, post-operative complications, and surgical re-interventions. One-year survival was 68.9%. Conclusion: Electrical storm is a rare indication of HT but may be lifesaving in those patients presenting intractable arrhythmias despite usual care. Most patients can be safely discharged from hospital, although post-operative mortality remains substantial in this context of emergency transplantation. Larger studies are warranted to precisely determine those patients at higher risk of in-hospital mortality.

Background: The prevalence and impact of coronary emboli (CE) in patients with ST‐segment–elevation myocardial infarction (STEMI) and atrial fibrillation (AF) have not been specifically studied. The objective was to describe the clinical characteristics and outcomes of patients with AF and CE in a large series of patients with STEMI. Methods and Results: We investigated 2292 consecutive patients with STEMI and among them 225 patients with AF: 46 patients with a STEMI related to CE (group A) and 179 patients with a STEMI related to an atherosclerotic cause (group B). Compared with the 2067 patients without AF and CE (group C), patients with AF and CE were older (73 versus 59 years, P <0.05), more likely to be female (43% versus 22%, P <0.05), and presented more frequently with cardiogenic shock at admission (26% versus 9%, P <0.05). The baseline characteristics of patients with AF (group A versus B) did not differ significantly according to STEMI pathogenesis. In the unadjusted analysis, the 45‐day mortality was higher in patients with CE and AF (group A versus group C: 20% versus 4%; P <0.05 and group A versus group B: 20% versus 8%, P =not significant); this trend persisted at 2‐year follow‐up (group A versus group C: 24% versus 6%; P <0.05 and group A versus group B: 24% versus 17%, P =not significant). After stabilized inverse exposure probability weighting adjustment, a higher 45‐day mortality rate was confirmed in patients with CE and AF (group A versus group C: 18% versus 5%, P <0.05). Conclusions: In patients presenting with STEMI and AF, CE was associated with excess early mortality. Registration: URL: clinicaltrials.gov . Identifier: NCT05679843.

In France, mexiletine - a class I antiarrhythmic drug - can be prescribed for the symptomatic treatment of myotonia of the skeletal muscles in adult patients with myotonic dystrophy under a compassionate use programme. Mexiletine is used according to its summary of product characteristics, which describes its use for myotonia treatment in adult patients with non-dystrophic myotonia, a different neuromuscular condition without cardiac involvement. A cardiac assessment is required prior to initiation and throughout treatment due to potential proarrhythmic effects. The presence of conduction system disease, the most common cardiac manifestation of myotonic dystrophy, mandates repeated cardiac evaluations in patients with this condition, and becomes even more important when they are given mexiletine. A group of experts, including three neurologists and five cardiologists from French neuromuscular reference centres, were involved in a task force to develop a treatment algorithm to guide mexiletine use in myotonic dystrophy. The recommendations are based on data from a literature review of the safety of mexiletine-treated patients with myotonic dystrophy, the compassionate use protocol for mexiletine and the personal clinical experience of the experts. The main conclusion of the expert group is that, although existing safety data in mexiletine-treated patients with myotonic dystrophy are reassuring, cardiac assessments should be reinforced in such patients compared with mexiletine-treated patients with non-dystrophic myotonia. This expert opinion to guide mexiletine treatment in patients with myotonic dystrophy should help to reduce the risk of severe adverse events and facilitate interactions between specialists involved in the routine care of patients with myotonic dystrophy.

Background and Aims: There is a paucity of data on arrhythmia burden in patients with congenitally corrected transposition of the great arteries (ccTGAs). The present study sought to quantify the incidence of atrial arrhythmia (AA), ventricular arrhythmia (VA), and complete atrioventricular block (CAVB) in patients with ccTGA and identify associated factors. Methods: An international, multi-centre, retrospective cohort study was conducted in 29 tertiary hospitals (six countries) between 1990 and 2018. Primary analyses consisted of determining the incidence of a combined outcome consisting of AA, VA, or CAVB, along with its individual components. Factors associated with the different types of arrhythmias were assessed by uni-variable and multi-variable Cox regression analyses. Results: A total of 1131 patients with ccTGA were followed for 9.0 (interquartile range 4.0–17.2) years. Cumulative rates of the primary endpoint at 10, 15, and 20 years were 44.5%, 51.0%, and 58.8%, respectively. AA, VA, and CAVB occurred in 2.1, 1.4, and 2.0 cases per 100 person-years, respectively. In multi-variable analyses, surgery/intervention conferred a greater than three-fold higher risk of AA [hazard ratio (HR) 3.01, 95% confidence interval (CI) 1.90–4.78, P < .001]. Furthermore, surgery/intervention was significantly associated with a greater risk of VA (HR 1.73, 95% CI 0.98–3.05, P = .003) and CAVB (HR 3.65, 95% CI 2.20–6.05, P < .001). The left bundle branch block was associated with a higher risk of VA (HR 4.03, 95% CI 1.59–10.23, P = .003) and the right bundle branch block with a higher risk of CAVB (HR 3.71, 95% CI 1.81–7.63, P < .001). Conclusions: The arrhythmia burden in patients with ccTGA is substantial, with a high incidence of AA, VA, and CAVB.