Search

Over the past 30 years, treatment paradigms for atrial fibrillation (AF) patients have changed dramatically. Before 1989, and the publication of the CAST trial results, the primary objective was to maintain or restore sinus rhythm. In the following 20 years, the management of AF patients has focused on the prevention of thrombo-embolic events (with the confrontation of aspirin and oral anticoagulants), and on the debate between rhythm control and rate control. In 2010, the objectives are to reduce symptoms and improve quality of life, to prevent thrombo-embolic complications, and, if possible, to reduce mortality. New anticoagulants will soon be available. Ablative techniques are becoming current practice in selected patients, and the new antiarrhythmic agent dronedarone has shown remarkable clinical results in the ATHENA trial. Overall, ablative techniques can be used in younger patients with paroxysmal or persistent AF refractory to medical treatment a rate control strategy is appropriate in permanent AF, or as second line treatment in patients with other forms of AF.

Antithrombotic treatment is a crucial challenge in the management of patients with atrial fibrillation (AF). It is the only treatment which can decrease mortality in relation with AF. It can also prevent the first cause of dependency in elderly: stroke. Vitamin K antagonists are the more potent drugs to reduce the risk of ischemic stroke in patient with AF. Aspirin, unfractioned heparine or low molecular weight heparin and thienopyridine can also play a role in the antithrombotic therapy in special situations.

Over the past 30 years, treatment paradigms for atrial fibrillation (AF) patients have changed dramatically. Before 1989, and the publication of the CAST trial results, the primary objective was to maintain or restore sinus rhythm. In the following 20 years, the management of AF patients has focused on the prevention of thrombo-embolic events (with the confrontation of aspirin and oral anticoagulants), and on the debate between rhythm control and rate control. In 2010, the objectives are to reduce symptoms and improve quality of life, to prevent thrombo-embolic complications, and, if possible, to reduce mortality. New anticoagulants will soon be available. Ablative techniques are becoming current practice in selected patients, and the new antiarrhythmic agent dronedarone has shown remarkable clinical results in the ATHENA trial. Overall, ablative techniques can be used in younger patients with paroxysmal or persistent AF refractory to medical treatment a rate control strategy is appropriate in permanent AF, or as second line treatment in patients with other forms of AF.

Antithrombotic treatment is a crucial challenge in the management of patients with atrial fibrillation (AF). It is the only treatment which can decrease mortality in relation with AF. It can also prevent the first cause of dependency in elderly: stroke. Vitamin K antagonists are the more potent drugs to reduce the risk of ischemic stroke in patient with AF. Aspirin, unfractioned heparine or low molecular weight heparin and thienopyridine can also play a role in the antithrombotic therapy in special situations.

To describe the management of patients with atrial fibrillation (AF) and to study consistency with guidelines on management of AF.Observational study on a random sample of cardiologists from a French national database. Each cardiologist had to recruit the first five patients meeting inclusion criteria (patients diagnosed with AF between January 2004 and one month before inclusion and accepting the collection of their medical data).Between December 2006 and January 2207, 1789 patients aged 71 on average have been recruited by 481 cardiologists. Fifty-one percent were diagnosed with paroxysmal, 15% with persistent and 33% with permanent AF. Restoration of sinus rhythm was preferred in forms considered as paroxysmal or persistent forms whereas control of the ventricular rate was more frequent in AF considered as permanent. Overall, therapeutic guidelines are applied in practice, despite a frequent use of amiodarone in patients with no associated heart disease. Prevention of thromboembolism was observed in 88% of the patients.FACTUEL is the biggest observational study on AF ever conducted in France. The therapeutic strategies used by the cardiologists are consistent with the objectives of preventing thromboembolism and controlling heart rhythm and/or rate. In most cases, the treatment used is consistent with the therapeutic guidelines.

During these last years, several therapeutic strategies trials have been performed in atrial fibrillation: the goal was to compare the rhythm control strategy (restoration and maintenance of sinus rhythm) to the rate control strategy (slowing of heart rate in atrial fibrillation). The most important of these different trials is the AFFIRM study. The main conclusion of this trial is that rate control can be chosen in first intention and not only in case of failure of the rhythm control strategy. These results can not be applied to 2 categories of patients: on one hand patients with heart failure and on the other hand young patients without cardiopathy in whom the strategy of rhythm control and sinus rhythm maintenance, mainly by class I antiarrhythmic drugs, remains the better choice.

Pacemaker lead infection is a major complication of endovascular permanent pacing. The incidence is less than 1% but it is a frequent disease due to the high number of pacemaker implanted. The diagnosis is difficult due to the insidious symptoms. Pacemaker infection must be systematically considered in patients with a pacemaker and symptoms of infection. Several investigations are useful for the diagnosis particularly the transesophageal echocardiography, but all investigations have a low negative predictive value. All of the implanted material must be completely removed.

Several authors have reported the single atrioventricular (AV) electrode, comprising an atrial dipole floating in the right atrium, to be a system capable of providing results which are just as satisfactory as those of conventional systems (DDD). Between August 1992 and March 1995, a VDD single electrode pacemaker was implanted in 65 patients (mean age: 73 years +/- 17.2). The indication for implantation was isolated high degree AVB with no apparent sinus dysfunction. Four pacemakers were used: Vitatron (n = 24), Intermedics (n = 23), Medico (n = 13), Biotronik (n = 5). Intraoperative atrial endocavitary recording was 1.8 mV +/- 0.74. 17 patients died from a cause unrelated to pacemaker dysfunction. 4 patients were lost to follow-up. The remaining 44 patients were reviewed in our centre with a mean follow-up of 14.5 months +/- 7 months. Seven pacemakers (16%) were reprogrammed in VVI or VVI (R) mode, because of permanent atrial fibrillation in 3 cases, complete loss of atrial reception in 2 cases and late onset sinus dysfunction in 1 case. In the 41 patients in sinus atrial rhythm, the atrioventricular synchronization rate was greater than 90% in 88% of patients, equal to 76.3% in 2.4% of patients and atrioventricular synchronization was impossible in 9.6% of cases.The overall results of our preliminary experience of VDD mode single electrode pacemaker are moderate. The poor results essentially concerned patients with paroxysmal atrial arrhythmias prior to pacing.

In order to evaluate the determinants of malignant vasovagal syncope with asystole revealed by the tilting test and to determine the possible therapeutic implications, 179 patients (91 women and 88 men, mean age 36.6 +/- 20.1 years) referred for the assessment of unexplained a were studied. The test was performed with a tilt of 60 degrees for 45 minutes. A bolus of isoprenaline (0.02 to 0.08 microgram/kg.min) was injected in the case of a negative passive test. Asystole was defined as a ventricular pause lastingor = 5 seconds.Ten (13%) of the 77 patients with a positive tilting test experienced a cardio-inhibitory reaction with prolonged asystole lasting an average of 11.9 +/- 4.9 seconds. Compared to the other 67 patients with a positive test, those with asystole were younger (23/9 +/- 14.8 years vs 32.9 +/- 18.5 years, NS) and had a more frequent history of convulsions (6/10 vs 9/67, p = 0.05) during spontaneous episodes and trauma (9/10 vs 27/67, p = 0.005). Implantation of a pacemaker was chosen first-line treatment for the first 6 patients. Their follow-up tilting tests remained positive (pre S = 4, S = 1) despite DDD stimulation of 45 bpm. Five of these patients and the following 4 patients were retested under beta-blockers. In six patients treated with beta-blockers, the clinical symptoms resolved completely (n = 3) or improved (n = 3), in contrast with 3 other patients in whom the tilting test remained positive with recurrence of asystole. The mean follow-up for the 169 patients is 22.7 +/- 11 months and the ten patients with asystole remained totally asymptomatic.An asystolic response during the tilting test is characteristic of vasovagal syncope described as malignant. The syndrome essentially affects young patients, with a more frequent history of trauma and convulsions. Beta-blockers appear to be at least as effective as permanent pacemaker to prevent symptoms in this specific subgroup.

In the context of an open multicentre study, 593 patients participated in the evaluation of sustained release disopyramide (*) in the treatment of cardiac arrhythmias. One hundred and seventy one (29%) had a ventricular arrhythmia, 382 (64%) a supraventricular arrhythmia and 40 (7%) an atrial and ventricular arrhythmia. Two hundred and seventy patients (46%) had underlying cardiac disease. Disopyramide was administered at the mean daily dose of 462 +/- 95 mg. The effectiveness of treatment was assessed after 3 and 6 months by Holter in the group treated for ventricular arrhythmias, the responder rate was 52.6% at three months and 58.1% at 6 months. It was significantly (p0.001) greater in the group treated for supraventricular arrhythmias (71.3% at 3 months and 82.1% at 6 months). The Holter responder rate in patients aged over 65 (70.5% at 6 months) was high and general and cardiac acceptability similar to that in younger patients. Adverse events led to the interruption of treatment in 8.2% of patients. Thus the effectiveness/acceptability ratio of SR disopyramide makes it entirely appropriate for the treatment of cardiac arrhythmias, even in the elderly.

After having reported the case of a pheochromocytoma associated to Recklinghausen's disease, the authors define the best criteria of detection and localization of the pheochromocytoma and study its association to phacomatoses. Headaches, bouts of tachycardia and excessive inappropriate diuresis are the most evocative clinical signs of a pheochromocytoma. The different hormones and their urinary metabolites must be titrated separately and repeatedly. Two other examinations, scanner and scintigraphy with MIBG, visualize quite reliably the tumor foci. Calcium inhibitors are quite effective in sudden blood pressure rises. The association described here, may be explained by the fact that the two pathologies belong to the group of neurocristopathies.

Bleomycin is sometimes at the origin of a Raynaud's phenomenon (RP). From the literature, there does not seem to exist a dose-dependent relationship. The phenomenon occurs early or late and often is resistant to various medications. The possible physiopathological mechanisms are: direct vascular toxicity, hypersensitivity vascularization, alteration of platelets activity, alteration of Willebrand's factor, and as predisposing factors: association to periwinkle alkaloids or hypomagnesemia.

We are reporting a case of malignant pheochromocytoma surgically treated initially for an isolated left pararenal localization, and which recurred several years later accompanied with numerous metastases. Despite of a treatment with Iodine 131 MIBG, the evolution was rapidly fatal with a picture of cardiac failure. This cardiac involvement would be linked to a myocarditis directly secondary to the catecholamines and causing a marked increase of the free fatty acids concentration in the heart tissue. In reference to this case, all the data which may tend to suspect the malignant nature of a pheochromocytoma, present in 10 p. cent of the cases, are successively reviewed. There is no clinical specificity. The presence of a mixed secretion with marked urinary dopamine secretion, would not present, for all authors, the same criteria of specificity. Thoraco-abdominal scan and scintigraphy with iodine 131 MIBG are the two tests permitting to demonstrate, with a great sensitivity and specificity, an extra-adrenal localization, which is the best argument in favor of a malignancy since 30 to 40 p. cent of extra-adrenal pheochromocytomas are malignant, more especially as the metastases are located in areas where there are no embryonic remnants of tissues containing chromaffin cells. This permits to appreciate the difference between a non-malignant multicentric pheochromocytoma and a malignant pheochromocytoma. The ideal treatment of a malignant pheochromocytoma rests on surgery under the condition that there are ony one or two metastases. This procedure is preceded by a sodium nitroprusside preparation and followed with an alpha-blockers treatment. In case of multiple metastases, the therapeutic use of iodine 131 MIBG seems to be a tempting alternative.

The recording of late ventricular potentials with high amplification cardiography (HAC) permits to identify patients presenting a risk of sudden death and ventricular tachycardia, especially in the later stage of myocardial infarction. Few authors have studied the prevalence of these potentials in other heart diseases presenting a risk of sudden death. Most series in the literature are too small to specify variations in the prevalence of these potentials according to the severity of the coronary disease. For this purpose, 835 patients including 535 coronary patients were evaluated with HAC compared to data from coronary angiography and Holter test. An automatic quantification method of the late potentials was used on 131 healthy subjects. The prevalence of late potentials is 32 p. cent after infarction, and 75 p. cent when a chronic ventricular tachycardia is present. These potentials retain their significance of tracers of ventricular arrhythmias in primary dilated myocardiopathies, with a prevalence of 25 p. cent reaching 50 p. cent in case of ventricular tachycardia. Their recording in the presence of idiopathic ventricular extrasystoles must be an indication to look for an underlying cardiopathy. It is possible to record them in other diseases especially in advanced valvular cardiopathies, as well as in right ventricular dysplasias with arrhythmia where their presence has a great diagnostic value.

A case of left intraventricular thrombus, developed from a myxoid mitral valve and revealed by embolic cerebral vascular accidents at the end of a pregnancy, is reported. The links between a mitral valve prolapse and cerebral vascular accidents of embolic origin are studied during pre- and post-partum periods, where coagulation alterations are reviewed. It appears that, in pregnant women with a mitral valve prolapse, there is a maximum risk of developing an intra-cardiac thrombus in the last four weeks of pregnancy or immediately after delivery; this justifies, during that time, a thorough sonocardiographic monitoring.

The decision of whether or not to treat a ventricular extrasystole depends in the first instance on the benign or severe nature of the disorder, and on whether there is subjacent cardiopathy. The results of 24-hour Holter monitoring, exercise tolerance tests and clinical and echographic examinations will define the pathological character of a ventricular extrasystole and will indicate any subjacent cardiopathy. Electrophysiological exploration with programmed stimulation should be reserved for so-called lethal cases of arrhythmia, such as attacks of sustained ventricular tachycardia. Ischemic cardiopathy is by far the most frequent cause of ventricular extrasystoles. The two major risks of sudden death after myocardial infarction are due to left ventricular dysfunction and repetitive and/or complex ventricular extrasystoles, as well as to attacks of ventricular tachycardia. Heart patients presenting these disorders must receive urgent treatment with antiarrhythmics. Isolated, monomorphic ventricular extrasystoles are also treated in heart patients at risk if their frequency is greater than 10 per hour, measured by 24-hour Holter monitoring. In the absence of subjacent cardiopathies, the therapeutic indications are much less well defined. Approximately five per cent of subjects in a normal population present ventricular extrasystoles, the frequency of which, however, rarely exceeds 100 per 24 hours. Repetitive phenomena are only seen in 10 per cent of cases. Attacks of ventricular tachycardia are almost never seen. Ventricular extrasystoles that develop in apparently normal hearts, but which do not fulfill the above criteria, can be considered abnormal. Nevertheless, there is no categorical proof that these ventricular extrasystoles represent any risk, notably of sudden death.(ABSTRACT TRUNCATED AT 250 WORDS)