[Show abstract][Hide abstract] ABSTRACT: Patients scheduled for atrial fibrillation (AF) cardioversion were excluded from clinical trials of novel oral anticoagulants (NOACs).We evaluated efficacy and safety of NOACs in patients undergoing electrical cardioversion for AF.We performed a monocentric study of all patients on NOACs who underwent elective electrical cardioversion for non-valvular AF between January 2012 and December 2014. We analyzed incidence of stroke and bleeding at 30 days.Fifty patients were included, 28 receiving dabigatran, 22 rivaroxaban. Mean age was 65 ± 12 years. Mean CHADS2-VA2SC and HASBLED scores were 3 ± 1.8 and 2.2 ± 1.1 respectively. Transoesophageal echocardiography was performed in 41 (79%) patients, revealing a thrombus in 2 (5%). No clinical evidence of stroke occurred in the 30 days, 1 major gastrointestinal bleeding (2%) in patient on rivaroxaban (led to premature discontinuation) and 3 minor bleedings.NOACs seem to be safe in daily practice of electrical cardioversion in our population.
[Show abstract][Hide abstract] ABSTRACT: Les troubles du rythme cardiaque peuvent survenir sur un coeur apparemment sain ou compliquer une cardiopathie sous-jacente. Ils peuvent entraîner une gêne fonctionnelle parfois importante, une syncope, une insuffisance cardiaque, un accident thromboembolique ou une mort subite. Leur traitement associe médicaments antiarythmiques et/ou ablation, le choix dépendant de l’arythmie, du terrain, des avantages et risques de chaque stratégie et de la préférence du patient. L’ablation est la destruction de la structure responsable de l’arythmie, au moyen d’une source d’énergie, qui est le plus souvent la radiofréquence et dans certains cas la cryothérapie. Cette revue se propose de faire le point sur la place des techniques ablatives dans le traitement de la fibrillation atriale, du flutter atrial, de la réentrée intranodale, du syndrome de Wolff-Parkinson-White et des tachycardies ventriculaires. Abstract Cardiac arrhythmias can be primitive or associated with a variety of cardiovascular conditions. Arrhythmias may be responsible for an important alteration of quality of life, syncope, heart failure, thromboembolic events, or sudden death. Their treatment includes antiarrhythmic medications and/or ablation. The choice is influenced by the type of arrhythmia, medical history, benefits and risks of each strategy in an individual patient, and patient preference. Ablation is the destruction of the cardiac structure responsible for the arrhythmia by using a source of energy which is usually radiofrequency and in some cases cryotherapy. We review the indications of ablation techniques in the treatment of atrial fibrillation, atrial flutter, atrioventricular nodal reentry, Wolff-Parkinson-White syndrome, and ventricular tachycardia.
[Show abstract][Hide abstract] ABSTRACT: In cardiac resynchronization therapy (CRT), the electrical impulse delivered by the left ventricular (LV) lead may incidentally cause phrenic nerve stimulation (PNS). The purpose of this state-of-the-art review is to describe the frequency, risk factors, and clinical consequences of PNS and to present the most recent options to successfully manage PNS. PNS occurs in 2 to 37 % of implanted patients and is not always detected in the supine position during implantation. Lateral and posterior veins are at higher risk of PNS than anterior veins, and apical positions are at higher risk of PNS than basal positions. The management of PNS discovered during implantation may include mapping the course of the target vein in order to find a PNS-free site, targeting another vein if available, and pacing with alternative configurations before changing the lead location. Non-invasive options for management of post-operative PNS depend on the difference between PNS and LV stimulation thresholds and include reducing the LV pacing output, automatic determination of LV stimulation threshold and minimal output delivery by the device, increasing the pulse duration, and electronic repositioning. New quadripolar leads allow to pace from different cathodes, and the multiple pacing configurations available have proved superior to bipolar leads in mitigating PNS. This electronic repositioning addresses almost all of the clinically relevant PNS and should markedly reduce the need for invasive lead repositioning or CRT abandon, which is actually the last option for 2 % of patients.
No preview · Article · Jun 2014 · Journal of Interventional Cardiac Electrophysiology
[Show abstract][Hide abstract] ABSTRACT: Insufficient correction of mechanical dyssynchrony is a cause of non-response to cardiac resynchronization therapy (CRT).
To determine if CRT delivery could be optimized during the implantation procedure by choosing the number and location of pacing sites using echocardiography guidance.
In patients with a QRS≥150ms or a QRS<150ms and criteria for mechanical dyssynchrony, the objective of the implantation procedure was to shorten the left pre-ejection interval (LPEI), measured online, by at least 10ms compared with standard biventricular configuration, by moving the right ventricular (RV) lead at different locations and, if necessary, by adding a second RV lead.
Ninety-one patients (70 men; mean age 73±10 years; left ventricular [LV] ejection fraction 29±10%) were included. The final pacing configuration was standard biventricular in 15 (17%) patients, optimized biventricular in 22 (24%) and triple-site ventricular in 54 (59%). LPEI was shortened by ≥ 10ms compared with standard biventricular stimulation in 73 (80%) patients. Compared with standard biventricular pacing, the final optimized pacing configuration improved global intraventricular synchrony (decreasing LPEI from 158±36ms to 134±29ms; P<0.001), LV systolic efficiency (decreasing LPEI/LV ejection time from 0.58±0.18 to 0.46±0.13; P<0.001) and LV filling (increasing LV filling time/RR from 44±8% to 47±7%; P<0.001) and decreased mitral valve regurgitation.
Intraoperative echocardiography-guided placement of RV lead(s) during CRT implantation is feasible and acutely improves LV synchrony compared with standard biventricular stimulation.
[Show abstract][Hide abstract] ABSTRACT: Atrial fibrillation (AF) is a major cause of ischemic strokes, and it is assumed that occult intermittent episodes of AF are responsible for some of the seemingly cryptogenic strokes. Cardiac pacemakers feature rhythm diagnostic capabilities and data storage. We investigated whether pacemaker memory interrogation led to identification of undetected AF episodes prior to cryptogenic strokes.
The study enrolled all patients admitted between June 2010 and July 2013 for an acute cryptogenic stroke and who were implanted with a permanent pacemaker. Patients with a history of AF and a history of stroke with an identifiable origin were excluded. Pacemaker memories were interrogated to determine the presence of AF prior to the stroke and its temporal relationship with the stroke.
Fourteen patients (nine men and five women) with a median (interquartile range) age of 84.5 (82.25-87.5) years were included. Median CHADS2 and CHA2DS2-VASc scores were 2 (1-2.75) and 3.5 (3-4), respectively. Pacemaker memories were activated in 13 patients with atrial arrhythmia detection based on an atrial cutoff rate in 8 patients and on the detection of atrial rate acceleration in 5 patients. Electrograms were available for review in 10 patients. Unknown AF or atrial flutter was diagnosed previous to the stroke in six (43 %) patients. Four patients experienced more than one arrhythmia episode. The last episode occurred in the 48 h prior to stroke in three patients and in the previous 4 weeks in five patients. Anticoagulation was started after the stroke in all of these six patients.
Pacemaker interrogation has a high diagnostic yield in seemingly cryptogenic stroke, with frequent detection of occult AF. The causal link between AF and stroke is convincingly reinforced by their close temporal proximity, and anticoagulation is warranted in this clinical situation.
No preview · Article · Feb 2014 · Journal of Interventional Cardiac Electrophysiology
[Show abstract][Hide abstract] ABSTRACT: Electrophysiological studies and radiofrequency catheter ablations require single or multiple sheath placements through femoral vein cannulation. The objective of this study was to determine the incidence, predictors, and outcomes of deep vein thrombosis (DVT) following such procedures.
We prospectively enrolled 220 consecutive patients with a median age of 70 [60-79] years. The median duration of the procedures from insertion to removal of sheaths was 45 [30-75] min. At least two sheaths were inserted in 158 (72 %) of the cases. Duplex ultrasonography evaluation of the lower leg veins was performed 6 h after the procedure and revealed common femoral vein thrombosis in 11 (5 %) patients. All thrombi were partial and none was complete. Thrombi were mobile in four patients and extended to the external iliac vein in three patients. None of the patients presented with clinical signs of DVT or pulmonary embolism. Anticoagulation was prescribed for 2-4 weeks and a follow-up duplex ultrasonography obtained in the first seven patients revealed complete resolution of thrombi in all cases. On multivariate analysis, two predictors of thrombosis occurrence were identified: a greater sum of sheath diameters (odds ratio, 1.41 [95 % confidence interval, 1.25-1.60] per 1-French increase; p < 0.001) and a longer procedural duration (odds ratio, 1.02 [95 % confidence interval, 1.00-1.04] per 1-min increase; p = 0.04).
Asymptomatic femoral DVT occur in 5 % of electrophysiological studies and right-heart radiofrequency catheter ablations, particularly when large sheaths are inserted for a longer period. The role of anticoagulation in this clinical setting warrants further evaluation.
No preview · Article · Oct 2013 · Journal of Interventional Cardiac Electrophysiology
[Show abstract][Hide abstract] ABSTRACT: Sudden cardiac death (SCD) is frequent in patients with lamin A/C gene (LMNA) mutations and may be related to ventricular arrhythmias (VA).
We evaluated a strategy of prophylactic implantable cardioverter-defibrillator (ICD) implantation in LMNA mutation carriers with significant cardiac conduction disorders.
Forty-seven consecutive patients (mean age 38±11 yo, 26 men) were prospectively enrolled between March 1999 and April 2009. Prophylactic ICD implantation was performed in patients with significant cardiac conduction disorders: patients requiring permanent pacing for bradycardia or already implanted with a pacemaker at initial presentation, or patients with a PR interval > 0.24s and either complete left bundle branch block or nonsustained ventricular tachycardia (NSVT).
Twenty-one (45%) patients had significant conduction disorders and received a prophylactic ICD. Among ICD recipients, no patient died suddenly and 11 (52%) patients required appropriate ICD therapy during a median follow-up of 62 months. Left ventricular ejection fraction (LVEF) was ≥ 45% in 9 patients at the time of the event. Among the 10 patients without malignant VA, device memory recorded NSVT in 8 (80%). The presence of significant conduction disorders was the only factor related to the occurrence of malignant VA (hazard ratio 5.20, 95% confidence interval 1.14-23.53, p=0.03).
Life-threatening VAs are common in patients with LMNA mutations and significant cardiac conduction disorders, even if LVEF is preserved. ICD is an effective treatment and should be considered in this patient population.
No preview · Article · Jun 2013 · Heart rhythm: the official journal of the Heart Rhythm Society
[Show abstract][Hide abstract] ABSTRACT: Backround: Centenarians have been proposed as a model of successful aging but recent studies suggest a high prevalence of cardiovascular diseases. Some findings on their electrocardiograms (ECGs) are simply age-related and others mirror underlying diseases. We aimed to identify ECG features truly associated with extreme age.
Methods: Retrospective analysis of 55 centenarians hospitalized between January 2000 and June 2010. Each centenarian was matched with three octogenarians according to gender, presence of hypertension, aortic stenosis, heart failure, and ischemic heart disease.
Results: A history of hypertension was present in 32 (58%) centenarians, aortic stenosis in 6 (11%), heart failure in 8 (15%), and ischemic heart disease in 6 (11%). Centenarians had a higher heart rate than octogenarians (81 ± 15 bpm vs. 72 ± 15 bpm, respectively, P < 0.001) but were less frequently on beta-blockers (7% vs. 36%, respectively, P < 0.001). Centenarians displayed more frequently atrial premature beats than octogenarians (18% vs. 3%, respectively, P < 0.001) but tended to have less atrial fibrillation (15% vs. 22% respectively, P = 0.21). Centenarians had more frequently left QRS axis deviation (48% vs. 28%, P = 0.009) and Q waves (14% vs. 1%, P = 0.02). QT interval was more prolonged in centenarians (446 ± 42 ms vs. 429 ± 39 ms, P = 0.008). Two centenarians (4%) and 24 (15%) octogenarians had a strictly normal ECG (P = 0.02).
Conclusions: Abnormal ECG is a common finding in centenarians, with different characteristics than in younger elderly individuals. These differences are unrelated to the presence of cardiac diseases.
No preview · Article · Oct 2012 · Annals of Noninvasive Electrocardiology
[Show abstract][Hide abstract] ABSTRACT: Cardiac amyloidosis due to familial amyloid polyneuropathy (FAP) includes restrictive cardiomyopathy, thickened cardiac walls, conduction disorders and cardiac denervation. Impaired blood pressure variability has been documented in FAP related to the Val30Met mutation.
To document blood pressure variability in FAP patients with various mutation types and its relationship to the severity of cardiac involvement.
Blood pressure variability was analysed in 49 consecutive FAP patients and was compared with a matched control population. Cardiac evaluation included echocardiography, right heart catheterization, electrophysiological study, Holter electrocardiogram and metaiodobenzylguanidine (MIBG) scintigraphy.
A non-dipping pattern was found in 80% of FAP patients and in 35% of control patients (P<0.0001); this was due to a significantly lower diurnal blood pressure in FAP patients (FAP group, 113 ± 21 mmHg; control group, 124 ± 8 mmHg; P<0.0001), whereas nocturnal blood pressures were similar. Among FAP patients, a non-dipping pattern was significantly associated with haemodynamic involvement, cardiac thickening or conduction disorders. These associations did not depend on the average blood pressure levels. Impaired blood pressure variability was more frequent and more pronounced in patients with multiple criteria for severe cardiac amyloidosis.
Low blood pressure variability is common in cardiac amyloidosis due to FAP. A non-dipping pattern was more frequently observed in FAP patients with haemodynamic impairment, cardiac thickening or conduction disorders. It is suggested that impairment of circadian rhythm of blood pressure reflects the severity of cardiac amyloidosis due to FAP.
Full-text · Article · May 2012 · Archives of cardiovascular diseases
[Show abstract][Hide abstract] ABSTRACT: Background: Recommended medications are under-prescribed in elderly patients with atrial fibrillation (AF), coronary artery disease (CAD), and congestive heart failure (CHF). The relationship between under-prescribing and comorbidity is unclear.Design: Single-day observational study.Methods: Analysis of medications taken by patients aged 80 years or over at the time of their admission to cardiology units of 32 French hospitals. Comorbidity was measured using the Charlson comorbidity index (CCI).Results: The study included 510 patients (57% men, mean age 85 years). History of AF, CHF, and CAD was present in 213 (42%), 199 (39%), and 187 (37%) patients, respectively. CCI was 0 in 110 (22%), 1-2 in 215 (42%), and ≥3 in 185 (36%) patients. Vitamin K antagonists (VKA) were prescribed to 105 (49%) and aspirin to 86 (40%) patients with AF. CCI did not influence VKA prescription but influenced aspirin use, with lower prescription rates in patients with CCI 1-2 than CCI 0 or CCI ≥3 (p = 0.02). In CHF, angiotensin-converting enzyme inhibitors (ACEI) and β-blockers were prescribed to 80 (40%) and 96 (48%) patients, respectively. Rates of prescription of ACEI, β-blockers, statins, and aspirin in patients with CAD were 43%, 56%, 56%, and 66%, respectively. CCI level did not influence any medication use in CHF and CAD.Conclusion: Even in the absence of comorbidity, elderly patients with major cardiovascular diseases are denied from indicated medical treatments probably because of their age alone. Implementing measures to enhance awareness of treatment benefits and promote appropriate prescribing is necessary.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND AND METHODS: Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice. The substrate of AF is composed of a complex interplay between structural and functional changes of the atrial myocardium often preceding the occurrence of persistent AF. However, there are only few animal models reproducing the slow progression of the AF substrate to the spontaneous occurrence of the arrhythmia. Transgenic mice (TG) with cardiomyocyte-directed expression of CREM-IbΔC-X, an isoform of transcription factor CREM, develop atrial dilatation and spontaneous-onset AF. Here we tested the hypothesis that TG mice develop an arrhythmogenic substrate preceding AF using physiological and biochemical techniques. RESULTS: Overexpression of CREM-IbΔC-X in young TG mice (<8weeks) led to atrial dilatation combined with distension of myocardium, elongated myocytes, little fibrosis, down-regulation of connexin 40, loss of excitability with a number of depolarized myocytes, atrial ectopies and inducibility of AF. These abnormalities continuously progressed with age resulting in interatrial conduction block, increased atrial conduction heterogeneity, leaky sarcoplasmic reticulum calcium stores and the spontaneous occurrence of paroxysmal and later persistent AF. This distinct atrial remodelling was associated with a pattern of non-regulated and up-regulated marker genes of myocardial hypertrophy and fibrosis. CONCLUSIONS: Expression of CREM-IbΔC-X in TG hearts evokes abnormal growth and development of the atria preceding conduction abnormalities and altered calcium homeostasis and the development of spontaneous and persistent AF. We conclude that transcription factor CREM is an important regulator of atrial growth implicated in the development of an arrhythmogenic substrate in TG mice.
Full-text · Article · Nov 2011 · International journal of cardiology