Philip Aouate

Bio: Philip Aouate is an academic researcher from University of Paris. The author has contributed to research in topics: Cryoablation & Brugada syndrome. The author has an hindex of 6, co-authored 9 publications receiving 199 citations.

Ventricular tachycardia catheter ablation in arrhythmogenic right ventricular dysplasia: a 16-year experience.

Abstract: Arrhythmogenic right ventricular dysplasia (ARVD) is a structural heart disease affecting young adults that leads to cardiac rhythm disorders including supraventricular and mostly ventricular arrhythmias. Sudden death may be the first presentation of the disease. Ablation techniques have been used for the treatment of ventricular tachycardia in cases resistant to drug therapy. Radiofrequency is appropriate as a first approach for ventricular tachycardia ablation in ARVD; however, its effectiveness is less than 40% at the first session. Fulguration is effective for ventricular tachycardia ablation and should be used in the same session after ineffective radiofrequency ablation. However, fulguration requires expertise, general anesthesia, and more than one session in half of all patients.

Brugada ECG pattern: a physiopathological prospective study based on clinical, electrophysiological, angiographic, and genetic findings

Abstract: Introduction Brugada syndrome (BrS) is considered a primary electrical disease. However, morphological abnormalities have been reported and localized arrhythmogenic right ventricular (RV) dysplasia/cardiomyopathy (ARVD/C) may mimic its phenotype, raising the question of an overlap between these two conditions and making difficult the therapeutic management of patients with borderline forms. The main objective of this study was to assess prospectively the prevalence of BrS and ARVD/C on the basis of international criteria, in patients with BrS-ECG and normal echocardiography, looking for a potential overlap between the two pathologies. The secondary objectives were to describe and quantify angiographic structural alterations, hemodynamics, electrophysiology, and genetics in the setting of BrS-ECG. Materials and methods Hundred and fourteen consecutive patients matched in age underwent prospectively cardiac catheterization and quantitative biventricular contrast angiography to rule out a structural heart disease. Fifty-one patients with a BrS-ECG (BrS group, 7 F, 44 M, 43 ± 11 y) had a spontaneous or ajmaline-induced BrS coved type ECG. For angiographic comparison, 49 patients with localized ARVD/C but without ST segment elevation in the right precordial leads (14 F, 35 M, 39 ± 13 y) were also studied. They fulfilled international ESC/WHF 2000 criteria and presented angiographic localized forms, mainly confined to hypokinetic anteroapical zone (characterized by trabecular dysarray and hypertrophy), and/or diaphragmatic wall, thus resulting in RV normal volumes and preserved systolic function. These two populations were also compared with 14 control patients (7 F, 7 M, 38 ± 16 y). Among BrS group, we identified three main angiographic phenotypes: BrS group I = patients with normal RV (n = 15, 29%); BrS group II = patients with segmental RV wall motion abnormalities but no structural arguments for ARVD/C (n = 26, 51%); BrS group III = patients with localized abnormalities suggestive of focal ARVD/C (n = 10, 20%). Results Among BrS group, 34/51 patients (67%) fulfilled BrS HRS/EHRA 2005 criteria. Nineteen (37%) were symptomatic for aborted sudden death, agonal nocturnal respiration or syncope. Ventricular stimulation was positive in 14 patients (28%). Angiography showed RV abnormalities in 36/51 patients (71%) of BrS group (BrS groups II and III). Late potentials were present in 73% (100% sensitivity and NPV for an angiographic ARVD/C, but poor specificity and PPV, both 37%). In BrS group III, 8/10 patients (16% of BrS patients) finally fulfilled international ESC/WHF 2000 ARVD/C criteria and 5/10 (10% of BrS patients) fulfilled BrS diagnostic criteria. An overlap was observed in 4 patients (8% of BrS patients) who fulfilled both ARVD/C and BrS criteria. Among the 45 genotyped patients, only one presented a SCN5A mutation, whereas a TRPM4 mutation was found in another patient. Both belonged to BrS group II. MOG1 gene analysis was negative for all patients, as were PKP2, DSP, DSG2, and DSC2 analyzes performed in BrS group III. Conclusions Seventy-one percent of patients with a BrS-ECG had abnormal RV wall motion and 16 had structural alterations corresponding to localized (anteroapical and/or diaphragmatic) ARVD/C. Moreover, 8% of BrS-ECG patients fulfilled both BrS and ARVD/C criteria. Our results support the hypothesis of an overlap between BrS and localized forms of ARVD/C. Conversely, genetic screening was poorly contributive for both diseases in the present series.

Effects of inadvertent atrioventricular block on clinical outcomes during cryoablation of the slow pathway in the treatment of atrioventricular nodal re-entrant tachycardia

Abstract: Aims The study aimed at evaluating the long-term effects of transient atrioventricular (AV) block on clinical outcomes during atrioventricular nodal re-entrant tachycardia (AVNRT) cryoablation. Methods and results In 150 consecutive patients (39+ 14 years, ineffective anti-arrhythmic drugs 1.9+ 1.3), slow-pathway cryoablation for AVNRT was performed. A 7 Fr 6 mm-tip cryocatheter was used. After successful cryomapping (2308C), defined as jump abolition or AV nodal refractory period prolongation, cryoablation (2808C for 4 min) was applied if no AV block occurred. Atrioventricular nodal re-entrant tachycardia inducibility was checked after 30 min. Acute success (AVNRT non-inducibility) was achieved in 142 patients (95%). Overall, after a follow-up of 18+ 10 months, 118 of 150 patients (79%) were recurrence-free (including 2 patients for whom the procedure was unsuccessful). Among successful procedures, 116 of 142 (82%) patients were recurrence-free. During cryoablation, inadvertent transient AV block of varying degrees occurred in 34 patients (22.7%), namely, increased PR in 17 patients and a 2nd–3rd AV block in the remaining 17. In 24 patients, AV block occurred at the last effective site (increased PR in 13 patients and a 2nd–3rd AV block in 11). In the study population as a whole, univariate predictors of recurrence in the follow-up were AVNRT inducibility (P , 0.001), increased PR at the last effective site (P , 0.001), residual jump (P , 0.02), and small Koch’s triangle (X-ray distance , 11 mm between the His and coronary sinus ostium catheters; P , 0.02). Atrioventricular nodal re-entrant tachycardia inducibility (P , 0.03), increased PR (P , 0.01), and small Koch’s triangle (P , 0.04) were independently significant. For attempts at the last effective site, 3 groups of patients were compared: 13 patients with increased PR duration (Group A), 11 with a 2nd–3rd AV block (Group B), and 126 without AV block (Group C). Cryo-application time was 277+ 203 s in Group A, 75+ 87 s in Group B, and 253+ 135 s in Group C (A vs. B, P , 0.01; B vs. C, P , 0.001; and C vs. A, P ¼ NS). There was no statistical difference among groups in the atriogram/ventriculogram amplitude ratio at the site of the last attempt, unsuccessful acute procedure, small Koch’s triangle, and residual jump. Actuarial incidence of recurrence-free status at 12 months was 38% in A, 82% in B, and 82% in C (A vs. B, P , 0.05; B vs. C, P ¼ NS; and C vs. A, P , 0.001). Conclusion All AV blocks occurring during cryoablation were transient, confirming the safety of this method. An increased PR duration at the last effective site is associated with a higher recurrence rate, whereas a 2nd–3rd degree AV block has a recurrence rate similar to that of patients without AV block despite a shorter cryo-application time at the last site.

Propranolol Intoxication Revealing a Brugada Syndrome

Abstract: This is the first report of Brugada syndrome revealed by beta-blocker intoxication. A 24-year-old healthy man ingested propranolol (2.28 g) to commit suicide. After early gastric lavage, electrolytes, cardiac enzymes, chest X-ray, and echocardiography were normal. Dosages of psychotropic drugs were negative. ECG showed a typical coved-type pattern of Brugada syndrome. Follow-up showed partial ECG normalization of the discrete saddleback-type pattern. The ajmaline- test confirmed Brugada syndrome. These ECG modifications may be explained by the stabilizing membrane effect of high concentration of propranolol and/or inhibition of ICaL. This case illustrates the possible deleterious effects of beta-blockers in patients with Brugada syndrome.

Correlations between long-term results after cryoablation for atrioventricular nodal reentry tachycardia and a residual jump associated or not with a single echo

Abstract: Aims While in radiofrequency ablation for atrioventricular nodal reentry tachycardia (AVNRT) a residual jump and a single echo do not seem to substantially modify long-term results, in cryoablation procedures their effects are still under evaluation. The purpose of this study was to evaluate if a residual jump associated or not with an isolated echo is correlated with outcome. Methods and results Inclusion criteria: acute successful slow pathway cryoablation for slow-fast AVNRT. Exclusion criteria: use of a 4 mm tip cryocatheter, no baseline elicitable jump or inducible AVNRT, and unwanted persistent first degree atrioventricular (AV) block at the end of the procedure. Cryoablation (−80°C × 4 min) was applied after successful cryomapping. Atrioventricular nodal reentry tachycardia inducibility was checked 30 min later on and off isoproterenol. Acute success was defined as AVNRT non-inducibility. Among 332 patients (pts) who had undergone cryoablation from May 2002 to March 2010 in our institutions, 245 of them fulfilled the entry criteria (173 women, mean age 41 ± 16 years, ineffective drugs 1.3 ± 1.1). A 7-Fr 6-mm tip cryocatheter (CryoCath®) was used in all cases. Baseline AV nodal effective refractory period (ERP) was 271 ± 55 ms, post-procedural ERP 331 ± 60 ms ( P < 0.001), and the mean of the difference between baseline and post-procedural ERP 63 ± 38 ms. A/V ratio at successful site was 1 ± 0.4. Forty-four pts (18%) had a residual jump at the end of the procedure, and 14 of them had an associated single echo. Global cryoapplication time was 993 ± 797 s. During a follow-up of 40 ± 10 months, 43 pts (17.5%) had recurrences. At 12 months follow-up, actuarial rate of recurrence-free pts was 85% in the group without residual jump (201 pts), 63.3% with residual jump and no echo (30 pts), and 60.6% with residual jump associated with a single echo ( P < 0.003 among groups). Univariate predictors of recurrences were persistence of a residual jump ( P < 0.001) and total cryoapplication time ( P < 0.02). In a multivariate model, only residual jump was independently correlated with recurrences ( P < 0.01). Conclusions In patients undergoing AVNRT cryoablation, slow-pathway suppression is correlated with a better outcome. A single echo is associated with a recurrence risk similar to residual jump without echo. It may be suggested that pursuing a procedural endpoint up to slow pathway complete suppression may improve long-term success.

ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

Abstract: It is important that the medical profession plays a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting absolute and relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of such guidelines in the area of cardiovascular disease since 1980. The ACC/AHA Task Force on Practice Guidelines, whose charge is to develop, update, or revise practice guidelines for important cardiovascular diseases and procedures, directs this effort. The Task Force is pleased to have this guideline developed in conjunction with the European Society of Cardiology (ESC). Writing committees are charged with the task of performing an assessment of the evidence and acting as an independent group of authors to develop or update written recommendations for clinical practice. Experts in the subject under consideration have been selected from all 3 organizations to examine subject-specific data and write guidelines. The process includes additional representatives from other medical practitioner and specialty groups when appropriate. Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of particular tests or therapies are considered as well as frequency of follow-up and cost effectiveness. When available, information from studies on cost will be considered; however, review …

Treatment of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia: An International Task Force Consensus Statement.

Abstract: Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is an inheritable heart muscle disease that predominantly affects the right ventricle (RV) and predisposes to ventricular arrhythmias and sudden cardiac death (SCD).1–17 In the last three decades, there have been a significant number of studies defining the pathogenesis, genetic aspects, and clinical manifestations of the disease (See ‘Etiology, pathogenesis, diagnosis and natural history’ in the online-only Data Supplement). In 1994 and 2010, an International Task Force (ITF) document proposed guidelines for the standardized diagnosis of ARVC/D based on electrocardiographic (ECG), arrhythmic, morphological, histopathologic, and clinico-genetic factors.18,19 The growing knowledge regarding arrhythmic outcome, risk factors, and life-saving therapeutic interventions, make it particularly timely to critically address and place into perspective the issues relevant to the clinical management of ARVC/D patients. The present ITF consensus statement is a comprehensive overview of currently used risk stratification algorithms and approaches to therapy, either pharmacological or nonpharmacological, which often poses a clinical challenge to cardiovascular specialists and other practitioners, particularly those infrequently engaged in the management of ARVC/D. This document should be regarded as a guide to clinical practice where rigorous evidence is still lacking, because of the relatively low disease prevalence and the absence of controlled studies. Recommendations are based on available data derived from nonrandomized and observational studies and consensus within the conference panellists. When development of prognostic-therapeutic algorithms was controversial, management decisions were recommended to be individualized. Recommendation and level of evidence of specific management options were classified according to predefined scales, as outlined in Tables 1 and 2 (http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx). Because randomized studies are not available, most consensus recommendations on treatment of ARVC/D are based on data derived from follow-up registries and/or experts opinions (ie, level of evidence B or C). View this table: Table 1. Classes of Recommendations View this table: Table 2. Levels of Evidence All members of …

Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy Need for an International Registry

Abstract: Arrhythmogenic right ventricular (RV) dysplasia/cardiomyopathy (ARVD/C) is a heart muscle disease characterized by peculiar RV involvement and electrical instability that precipitates ventricular arrhythmias and sudden death. The purpose of the present consensus report of the Study Group on ARVD/C of the Working Groups on Myocardial and Pericardial Disease and Arrhythmias of the European Society of Cardiology and of the Scientific Council on Cardiomyopathies of the World Heart Federation is to review the considerable progress in our understanding of the etiopathogenesis, morbid anatomy, and clinical presentation of ARVD/C since it first was described in 1977. The present article focuses on important but still unanswered issues, mostly regarding risk stratification, clinical outcome, and management of affected patients. Because ARVD/C is relatively uncommon and any one center may have experience with only a few patients, an international registry is being established to accumulate information and enhance the numbers of patients that can be analyzed and thus answer pending questions. The registry also will facilitate pathological, molecular, and genetics research on the causes and pathogenesis of the ARVD/C. Furthermore, availability of an international database will enhance awareness of this largely unrecognized condition among the medical community. Physicians are encouraged to enroll patients in the International Registry of ARVD/C.