Despite the advent of non-fluoroscopic technology, fluoroscopy remains the cornerstone of imaging in most interventional electrophysiological procedures, from diagnostic studies over ablation interventions to device implantation. Moreover, many patients receive additional X-ray imaging, such as cardiac computed tomography and others. More and more complex procedures have the risk to increase the radiation exposure, both for the patients and the operators. The professional lifetime attributable excess cancer risk may be around 1 in 100 for the operators, the same as for a patient undergoing repetitive complex procedures. Moreover, recent reports have also hinted at an excess risk of brain tumours among interventional cardiologists. Apart from evaluating the need for and justifying the use of radiation to assist their procedures, physicians have to continuously explore ways to reduce the radiation exposure. After an introduction on how to quantify the radiation exposure and defining its current magnitude in electrophysiology compared with the other sources of radiation, this position paper wants to offer some very practical advice on how to reduce exposure to patients and staff. The text describes how customization of the X-ray system, workflow adaptations, and shielding measures can be implemented in the cath lab. The potential and the pitfalls of different non-fluoroscopic guiding technologies are discussed. Finally, we suggest further improvements that can be implemented by both the physicians and the industry in the future. We are confident that these suggestions are able to reduce patient and operator exposure by more than an order of magnitude, and therefore think that these recommendations are worth reading and implementing by any electrophysiological operator in the field.

The CREATE-ECLA Randomized Controlled TrialThe CREATE-ECLA Trial Group Investigators* See also pp 427 and 489.

No abstract

In terms of acute haemodynamic response, CRT3P-MPP was comparable an apical CRTSP and superior to basal and distal CRTSP. In the absence of within-device haemodynamic optimization, CRT3P-MPP may offer a haemodynamic advantage over a fixed CRTSP configuration.

Aims To determine whether myocardial fibrosis and greyzone fibrosis (GZF) on cardiovascular magnetic resonance (CMR) is associated with ventricular arrhythmias in patients with coronary artery disease (CAD) and a left ventricular ejection fraction (LVEF) >35%. Methods and results In this retrospective study of CAD patients, GZF mass using the 3SD method (GZF3SD) and total fibrosis mass using the 2SD method (TF2SD) on CMR were assessed in relation to the primary, combined endpoint of sudden cardiac death, ventricular tachycardia, ventricular fibrillation, or resuscitated cardiac arrest. Among 701 patients [age: 65.8 ± 12.3 years (mean ± SD)], 28 (3.99%) patients met the primary endpoint over 5.91 years (median; interquartile range 4.42–7.64). In competing risks analysis, a GZF3SD mass ≥5.0 g was strongly associated with the primary endpoint [subdistribution hazard ratio (sHR): 17.4 (95% confidence interval, CI 6.64–45.5); area under receiver operator characteristic curve (AUC): 0.85, P < 0.001]. A weaker association was observed for TF2SD mass ≥23 g [sHR 10.4 (95% CI 4.22–25.8); AUC: 0.80, P < 0.001]. The range of sHRs for GZF3SD mass (1–527) was wider than for TF2SD mass (1–37.6). Conclusions In CAD patients with an LVEF >35%, GZF3SD mass was strongly associated with the arrhythmic endpoint. These findings hold promise for its use in identifying patients with CAD and an LVEF >35% at risk of arrhythmic events.

Arrhythmias in adults with congenital heart disease, most commonly related to previous surgical procedures, are a frequent comorbidity in this growing population thanks to the improved outcome of surgical techniques. Re-entrant circuits around areas of scarring and natural barriers, combined with abnormal haemodynamics and the underlying anatomy, are the most common cause for these arrhythmias. They are often poorly tolerated and medical treatment is frequently inadequate. In recent years, catheter ablation has emerged as a successful therapeutic option. New advanced techniques such as the use of modern three-dimensional (3D) navigation systems have contributed to better understanding of the arrhythmia mechanisms and higher success rates of the ablation procedures.In this article we briefly summarise the characteristics of the most common arrhythmias in this patient population and some key aspects in their treatment by catheter ablation.

Conclusion Although our numbers are small, the incidence of complications during pregnancy or immediately post partum are similar to those that we quote to our patients. Pregnant and post partum women complaining of severe chest pain should be brought to the immediate attention of senior staff and investigated urgently. 74 NON-INVASIVE ASSESSMENT OF PULMONARY HAEMODYNAMICS IN FONTAN PATIENTSAderonke Abiodun*, Luke Pickup, Heather Moore, Sarah Bowater, Sara Thorne, Lucy Hudsmith, Paul Clift. Queen Elizabeth Hospital Birmingham; *Presenting Author 10. 1136/heartjnl-2016-309890.74 Introduction The Fontan circulation relies on a low pulmonary vascular resistance. At present the gold standard method of measuring this is with invasive cardiac catheterisation which can be difficult in this group. Previous work has shown that pulmonary vascular resistance is inversely correlated with pulmonary capacitance which can be approximated non-invasively using data derived from a maximal cardiopulmonary exercise test (CPEX). We have determined the non-invasive pulmonary artery capacitance (Ventilatory Product) in a large cohort of adult Fontan patients. Methods 220 patients under regular follow up at University Hospital Birmingham were identified and CPEX results were available for 131 patients. We subdivided these into two groups, those with an atriopulmonary Fontan (AP) and combined those with lateral tunnel and total cavo-pulmonary connexion (TCPC). Parameters obtained were: NYHA functional class, maximum workload, ventilatory product, peak oxygen consumption, peak end tidal CO 2 and VE/VCO 2 slope. Results 77 patients with TCPC/lateral tunnel versus 54 AP Fontan were included. In the AP Fontan group, mean ventilatory product correlated positively with pVO2 (r 2 =0.344) and maximum workload (r 2 =0.515) and negatively with VE/VCO 2 slope (r 2 =--0.366). In the combined TCPC/lateral tunnel Fontan group, mean ventilatory product correlated positively with pV02 (r 2 =0.484) and maximum workload (r 2 =0.485) and negatively with VE/VCO 2 slope (r 2 =-0.127). When determined for each functional class ventilatory product was as follows in TCPC/lateral tunnel group: NYHA I 355.8 +/-±100, NYHA II 272.14 ± 105, NYHA III 241.76 ± 90.3. In the AP Fontan group mean ventilatory product was as follows: NYHA I 349.2 ± 131.8, NYHA II 271.5 121.5, NYHA III 273.9 +/-140.6. The mean VO2 peak was significantly higher in the combined TCPC/lateral tunnel group (26.64 vs 20.56, p = 0.00). Further sub analysis within each functional class between both groups also showed statistical significance. TCPC/lateral NYHA class I mean V02 peak 29.56 vs 25.11 vs (p = 0.01), class II mean V02 peak 22.72 vs 18 (p = 0.038) and class III mean 22.14 vs 15.31 (p = 0.018). Discussion Invasive measurements of PVR are difficult in the Fontan patient. We have demonstrated that a non-invasive indirect measurement of pulmonary artery capacitance -the ventilatory product, correlates with measures of performance, and negatively correlates with VE/VCO 2 , which is known t...

IntroductionFabry disease (FD) is an X-linked lysosomal storage disorder caused by enzyme deficiency, leading to glycosphingolipid accumulation. Cardiac accumulation triggers local tissue injury, electrical instability and arrhythmia. Bradyarrhythmia and atrial fibrillation (AF) incidence are reported in up to 16% and 13%, respectively.ObjectiveWe conducted a systematic review evaluating AF burden and bradycardia requiring permanent pacemaker (PPM) implantation and report any predictive risk factors identified.MethodsWe conducted a literature search on studies in adults with FD published from inception to July 2019. Study outcomes included AF or bradycardia requiring therapy. Databases included Embase, Medline, PubMed, Web of Science, CINAHL and Cochrane. The Risk of Bias Agreement tool for Non-Randomised Studies (RoBANS) was utilised to assess bias across key areas.Results11 studies were included, eight providing data on AF incidence or PPM implantation. Weighted estimate of event rates for AF were 12.2% and 10% for PPM. Age was associated with AF (OR 1.05–1.20 per 1-year increase in age) and a risk factor for PPM implantation (composite OR 1.03). Left ventricular hypertrophy (LVH) was associated with AF and PPM implantation.ConclusionEvidence supporting AF and bradycardia requiring pacemaker implantation is limited to single-centre studies. Incidence is variable and choice of diagnostic modality plays a role in detection rate. Predictors for AF (age, LVH and atrial dilatation) and PPM (age, LVH and PR/QRS interval) were identified but strength of association was low. Incidence of AF and PPM implantation in FD are variably reported with arrhythmia burden likely much higher than previously thought.PROSPERO databaseCRD42019132045.