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Summary Background High-level physical training induces cardiac structural and functional changes, including 12-lead electrocardiogram modifications. Objectives The purpose of this cross-sectional longitudinal study was to establish a quantitative electrocardiographic profile in highly trained football players. Initial and serial annual electrocardiogram monitoring over subsequent years allowed us to investigate the long-term effects of exercise on cardiac conduction and electrophysiological remodelling. Methods Between 2005 and 2015, serial evaluations, including 12-lead electrocardiograms, were performed in 2484 elite male football players from the French Professional Football League. A total of 6247 electrocardiograms were performed (mean 2.5 ± 1.8 electrocardiograms/player). Heart rate (beats/min), atrioventricular delay (PR, ms), intraventricular conduction delay (QRS, ms), corrected QT delay (QTc) and electrical left ventricular hypertrophy (LVH) (Sokolow-Lyon index, mm) were measured, and the fixed effect of time was evaluated using panel data analysis (β [95% confidence interval] change between two visits). Results According to European Society of Cardiology and Seattle criteria, 15% of the electrocardiogram intervals were considered abnormal. We observed 17% sinus bradycardia 200 ms (mean PR 170 ± 27 ms), 1.5% QRS > 120 ms (mean QRS 87 ± 19 ms) and 3% prolonged QT interval (mean QTc using Bazett's formula [QTcB] 395 ± 42 ms). Electrical LVH (mean Sokolow-Lyon index 34 ± 10 mm) was noted in 37% of players. Over time, electrocardiogram changes were noted, with a significant remodelling trend in terms of decreased heart rate (−0.41 [−0.55 to −0.26] beats/min), QRS duration (−2.4 [−2.7 to −2.1] ms) and QTcB delay (−1.2 [−1.9 to −0.5] ms) (all P Conclusions This study describes usual electrocardiographic training-induced changes in a large series of football players over the follow-up timeframe. The most frequent outliers were electrical LVH and sinus bradycardia. These results have important implications for optimizing electrocardiogram interval measurements in initial screening and during follow-up of football players, with potential cost-effective implications.

Summary Background Right ventricular (RV) dysfunction is an important predictor of impaired prognosis in idiopathic dilated cardiomyopathy. Aims To determine the prognostic role of RV dysfunction, independent of left ventricular (LV) dysfunction. Methods A total of 136 consecutive patients (73% men; mean age 59.0 ± 13.2 years) with idiopathic dilated cardiomyopathy (LV ejection fraction ≤ 45%) were enrolled retrospectively. Thirty-four patients (25%, group 1) presented with RV dysfunction, defined as tricuspid annular plane systolic excursion (TAPSE) ≤ 15 mm; 102 patients (group 2) had preserved RV function. Results Mean LV ejection fraction was 27.5 ± 8.7%. Mean TAPSE was 18.6 ± 5.4 mm (15–21.8 mm). Multivariable predictors of RV dysfunction were LV outflow tract time-velocity integral (odds ratio 0.8, 95% confidence interval [CI] 0.7–0.9; P = 0.003) and E-wave deceleration time ≤ 145 ms (odds ratio 4.1, 95% CI 1.3–12.8; P = 0.017). Major adverse cardiac event-free survival rates at 1 and 2 years were 64% and 55%, respectively, in group 1 and 87% and 79%, respectively, in group 2 ( P = 0.002). Both by multivariable analysis and after stratification using a propensity score, RV dysfunction emerged as an independent predictor for major adverse cardiac events (hazard ratio 3.2, 95% CI 1.3–7.6; P = 0.009), along with right atrium area and age. Conclusion In idiopathic dilated cardiomyopathy, RV dysfunction with TAPSE ≤ 15 mm offers additional prognostic information, independent of the extent of LV dysfunction.

Atrial fibrillation (AF) is the most frequent cardiac rhythm disorder and presents a considerable public health burden that is likely to increase in the next decades due to the ageing population. Current management strategies focus on the heart rate and rhythm control, thromboembolism prevention, and treatment of underlying diseases. The concept of quality of life (QoL) has gained significant importance in recent years as an outcome measure in AF studies evaluating therapeutic interventions and as a relevant component of a comprehensive treatment plan. Quality of life is impaired in the majority of patients with AF, and both rate and rhythm control strategies show significant improvement in QoL measures in highly symptomatic patients. This article reviews generic and specialized instruments for measuring QoL in the context of AF, discusses their applications and limitations to integration in clinical practice, and addresses the potential of early therapy for improving QoL outcomes. The development and validation of new QoL assessment tools will have a central role in the advancement of therapies and treatment guidelines for AF.

Aims The Effectiveness and Cost of ICD follow-up Schedule with Telecardiology (ECOST) trial evaluated prospectively the economic impact of long-term remote monitoring (RM) of implantable cardioverter defibrillators (ICDs). Methods and results The analysis included 310 patients randomly assigned to RM (active group) vs. ambulatory follow-ups (control group). Patients in the active group were seen once a year unless the system reported an event mandating an ambulatory visit, while patients in the control group were seen in the ambulatory department every 6 months. The costs of each follow-up strategy were compared, using the actual billing documents issued by the French health insurance system, including costs of (i) (a) ICD-related ambulatory visits and transportation, (b) other ambulatory visits, (c) cardiovascular treatments and procedures, and (ii) hospitalizations for the management of cardiovascular events. The ICD and RM system costs were calculated on the basis of the device remaining longevity at the end of the study. The characteristics of the study groups were similar. Over a follow-up of 27 months, the mean non-hospital costs per patient-year were €1695 ± 1131 in the active, vs. €1952 ± 1023 in the control group ( P = 0.04), a €257 difference mainly due to device management. The hospitalization costs per patient-year were €2829 ± 6382 and €3549 ± 9714 in the active and control groups, respectively ( P = 0.46). Adding the ICD to the non-hospital costs, the savings were €494 ( P = 0.005) or, when the monitoring system was included, €315 ( P = 0.05) per patient-year. Conclusion From the French health insurance perspective, the remote management of ICD patients is cost saving. Clinical trials registration NCT00989417, [www.clinicaltrials.gov][1] [1]: http://www.clinicaltrials.gov

Bilateral internal mammary arteries (BIMA) remain widely underused in coronary artery bypass grafting (CABG). In this study, we aim to investigate the early and long-term outcomes of BIMA grafts in isolated CABGs.Single-centre retrospective observational study.University Hospital, Nancy.1000 consecutive patients undergoing elective, isolated, primary, multiple CABGs using BIMA grafts and supplemental venous grafts for multi-vessel coronary disease.In-hospital mortality and major morbidity, and long-term all-cause mortality.Mean age of the overall population was 60 ± 15 years. A left ventricular ejection fraction (LVEF) ≤ 45% was found in 28% of the patients and 27.1% of the patients were diabetics. Comorbidities were represented by chronic renal failure, chronic obstructive pulmonary disease and peripheral artery disease in 11, 11.7 and 27.3% of the cases, respectively. The in-hospital mortality rate was 2.8%. Early postoperative morbidity included myocardial infarction (2.2%), stroke (0.9%), mesenteric ischaemia (0.7%) and mediastinitis (2.2%). The Kaplan-Meier 8-year survival rates for patients less than 65 and between 65 and 74 years of age were 88% and 66%, respectively (p0.01). Multiple regression analysis showed that patients' age 65 years or greater at baseline (OR 2.3; 95% CI 1.3 to 4, p0.001), acute coronary syndrome (OR 1.9; 95% CI 1.1 to 3.4, p = 0.02), chronic renal failure (OR 2.7; 95% CI 1.4 to 5.2, p0.001), peripheral artery disease (OR 3.1; 95% CI 1.8 to 5.5, p0.001) and LVEF ≤ 45% (OR 2.6; 95% CI 1.4 to 4.5, p0.001) were independent predictors of long-term cardiovascular mortality.Our longitudinal analysis presents encouraging data concerning operative risk of BIMA grafting and provides excellent long-term survival in appropriately selected patients.

Stroke associated with left cardiac catheterization is a devastating complication, and its incidence has not changed over the decades. We investigated the incidence, in-hospital outcomes and the modifiable and non-modifiable risk factors for periprocedural ischemic stroke.Our retrospective cohort study included all patients experiencing periprocedural ischemic stroke among the 24,500 patients who underwent left cardiac catheterization between January 2003 and October 2010. The case group was compared with a group of control patients randomly selected among those who underwent the procedure during this period.Ischemic cerebrovascular events attested by brain imaging occurred in 37 patients (0.15% of procedures), transient ischemic attack occurred in 9 cases, and persistent neurological deficit occurred in 28 cases. Patients who developed strokes were more likely to be older and were more often female with a greater prevalence of comorbidities. Emergency and longer procedures were more frequent in patients in the case group who had more coronary complications. A multivariate analysis identified diabetes mellitus (adjusted odds ratio (OR) 4.2; 95% CI 1.8-9.9; P.001), chronic renal dysfunction (OR 2.4; 95% CI 1.1-5.4; P.001), known cerebrovascular disease (OR 5.1; 95% CI 2.3-11.5; P.001), emergency procedure (OR 3.1; 95% CI 1.4-9.2; P.01) and recent congestive heart failure (OR 6.1; 95% CI 2.9-13; P.001) as independent predictors for stroke. The independent modifiable predictive factors were represented by left ventricular angiography (OR 7.5; 95% CI 2.7-21; P.001), and low operator volume (OR 3.1; 95% CI 1.3-7.4; P.01).Limiting the performance of left cardiac catheterization to high volume operators and avoiding unnecessary left ventricular angiography may reduce periprocedural ischemic stroke.

Background: Multiple studies have shown that amiodarone is effective in treating atrial fibrillation (AF), but is associated with a relatively high incidence of side effects; however, due to amiodarone's long elimination half-life (20–100 days), physicians may hesitate to start other drugs until it has fully cleared. Hypothesis: A rapid switch from amiodarone to dronedarone is feasible. Methods: EURIDIS and ADONIS were double-blind, multinational, parallel-group trials comparing the efficacy and safety of dronedarone with placebo over 12 months. This retrospective subanalysis of EURIDIS/ADONIS compared the effects of dronedarone in patients discontinuing amiodarone within 2 days before randomization (“rapid switch”) with results in patients who had received no amiodarone during the 2 months preceding randomization. Results: In total, 1237 patients were enrolled (“rapid switch”, n = 154; “no amiodarone”, n = 1014). In both the “rapid switch” and the “no amiodarone” groups, dronedarone users had significantly lower AF recurrence than patients receiving placebo (HR = 0.64, 95% CI, 0.44–0.95; P = 0.0224 and HR = 0.79, 95% CI, 0.67–0.92; P = 0.0027, respectively). Dronedarone users had a higher incidence of bradyarrhythmic events than placebo-treated patients. A “rapid switch” from amiodarone to dronedarone was associated with a higher incidence of serious heart failure events and heart failure hospitalizations versus all other groups. Overall event rates were low and there was no significant difference in total adverse event rates or deaths between groups. Conclusion: In this patient population, a switch from amiodarone to dronedarone within a 2-day time frame might be feasible in certain patient categories, but further investigation is warranted. The ADONIS/EURIDIS studies and this post hoc analysis were funded by sanofi-aventis. The authors have no other funding, financial relationships, or conflicts of interest to disclose.

International audience; We herein present the findings of the case of a 23-year-old man who was hospitalized for ventricular tachycardia (VT) with no previous history of cardiac disease or any family history of sudden death. Based on the clinical features as well as the echographic and MRI results, the patient was diagnosed with both acute viral myocarditis and arythmogenic right ventricular dysplasia (ARVD). The patient underwent implantation of an automatic cardioverter defibrillator. There was no recurrent VT during the 24 month follow-up. This case demonstrates the link between ARVD and myocarditis, and highlights the importance of conducting an RV assessment through a cardiac magnetic resonance (CMR) study in the context of arrhythmia and myocarditis.

Aims The ECOST trial examined prospectively the long-term safety and effectiveness of home monitoring (HM) of implantable cardioverter defibrillators (ICD). Methods and results The trial's primary objective was to randomly compare the proportions of patients experiencing ≥1 major adverse event (MAE), including deaths from all causes, and cardiovascular, procedure-related, and device-related MAE associated with HM (active group) vs. ambulatory follow-ups (control group) in a sample of 433 patients. The 221 patients assigned to the active group were seen once a year, unless HM reported an ICD dysfunction or a clinical event requiring an ambulatory visit, while the 212 patients in the control group underwent ambulatory visits every 6 months. The characteristics of the study groups were similar. Over a follow-up of 24.2 months, 38.5% of patients in the active and 41.5% in the control group experienced ≥1 MAE ( P < 0.05 for non-inferiority). The overall number of shocks delivered was significantly lower in the active ( n = 193) than in the control ( n = 657) group ( P < 0.05) and the proportion of patients who received inappropriate shocks was 52% lower in the active ( n = 11) than in the control ( n = 22) group ( P < 0.05). At the end of the follow-up, the battery longevity was longer in the active group because of a lower number of capacitor charges (499 vs. 2081). Conclusion Our observations indicate that long-term HM of ICD is at least as safe as standard ambulatory follow-ups with respect to a broad spectrum of MAE. It also lowered significantly the number of appropriate and inappropriate shocks delivered, and spared the device battery. Clinical trials registration NCT00989417.

Aims Little is known about the optimal number of antitachycardia pacing (ATP) attempts to programme in the fast ventricular tachycardia (FVT) zone. We sought to analyse the long-term efficacy and safety of programming a high number of ATP attempts for FVTs. Methods and results All patients receiving an implantable cardioverter/defibrillator (ICD) for coronary artery disease or dilated cardiomyopathy for primary and secondary prevention between 2000 and 2009 were prospectively included. Implantable cardioverter/defibrillators were programmed to deliver 10 ATP attempts for FVT cycle lengths (CLs) of 250–300 ms (200–240 b.p.m.) before shock delivery (5 bursts, then 5 ramps; 8–10 extrastimuli at 81–88% FVT CL; minimal pacing CL 180 ms). Among 770 patients included and followed for 40.6 ± 25.6 months, 137 (17.8%) experienced a total of 1839 FVTs, 1713 of which were ATP-terminated (unadjusted efficacy = 93.1%, adjusted = 81.7%), 106 ATP-accelerated (5.8%), and 20 ATP-resistant (1.1%). The majority of FVT episodes were successfully treated by one or two attempts (98.3%). However, patient-based analysis showed that 17 (12.4%), 8 (5.8%), and 5 patients (2.1%) had at least one episode treated by three or more, four or more, and five or more ATP attempts. The benefit of this strategy was reduced after five attempts. The majority of FVT episodes was asymptomatic and diagnosed at device interrogation during follow-up: syncope and pre-syncope occurred in only 0.2 and 0.4% of episodes, respectively. Conclusion Programming a high number of ATP attempts (up to five ATP attempts) in the FVT zone is both safe and efficient and could prevent shocks in numerous ICD recipients.

Atrial fibrillation (AF) is the most common sustained arrhythmia and an important source for mortality and morbidity on a population level. Despite the clear association between AF and death, stroke, and other cardiovascular events, there is no evidence that rhythm control treatment improves outcome in AF patients. The poor outcome of rhythm control relates to the severity of the atrial substrate for AF not only due to the underlying atrial remodelling process but also due to the poor efficacy and adverse events of the currently available ion-channel antiarrhythmic drugs and ablation techniques. Data suggest, however, an association between sinus rhythm maintenance and improved survival. Hypothetically, sinus rhythm may also lead to a lower risk of stroke and heart failure. The presence of AF, thus, seems one of the modifiable factors associated with death and cardiovascular morbidity in AF patients. Patients with a short history of AF and the underlying heart disease have not been studied before. It is fair to assume that abolishment of AF in these patients is more successful and possibly also safer, which could translate into a prognostic benefit of early rhythm control therapy. Several trials are now investigating whether aggressive early rhythm control therapy can reduce cardiovascular morbidity and mortality and increase maintenance of sinus rhythm. In the present paper we describe the background of these studies and provide some information on their design.

Atrial fibrillation (AF) is the most common arrhythmia in clinical practise and its prevalence is increasing. Over the last 25 years, flecainide has been used extensively worldwide, and its capacity to reduce AF symptoms and provide long-term restoration of sinus rhythm (SR) has been well documented. The increased mortality seen in patients treated with flecainide in the Cardiac Arrhythmia Suppression Trial (CAST) study, published in 1991, still deters many clinicians from using flecainide, denying many new AF patients a valuable treatment option. There is now a body of evidence that clearly demonstrates that flecainide has a favourable safety profile in AF patients without significant left ventricular disease or coronary heart disease. As a result of this evidence, flecainide is now recommended as one of the first-line treatment options for restoring and maintaining SR in patients with AF under current treatment guidelines. The objective of this article is to review the literature pertaining to the pharmacological characteristics, safety and efficacy of flecainide, and to place this drug in the context of current therapeutic management strategies for AF.

Venice Chart International Consensus Document on Ventricular Tachycardia/Ventricular Fibrillation Ablation ANDREA NATALE, M.D.,∗ ANTONIO RAVIELE, M.D.,† AMIN AL-AHMAD, M.D.,‡ OTTAVIO ALFIERI, M.D.,¶ ETIENNE ALIOT, M.D.,∗∗ JESUS ALMENDRAL, M.D.,†† GUNTER BREITHARDT, M.D.,‡‡ JOSEP BRUGADA, M.D.,¶¶ HUGH CALKINS, M.D.,∗∗∗ DAVID CALLANS, M.D.,††† RICCARDO CAPPATO, M.D.,‡‡‡ JOHN A. CAMM, M.D.,¶¶¶ PAOLO DELLA BELLA, M.D.,∗∗∗∗ GERARD M. GUIRAUDON, M.D.,†††† MICHEL HAISSAGUERRE, M.D.,‡‡‡‡ GERHARD HINDRICKS, M.D.,¶¶¶¶ SIEW YEN HO, M.D.,∗∗∗∗∗ KARL H. KUCK, M.D.,††††† FRANCIS MARCHLINSKI, M.D.,‡‡‡‡‡ DOUGLAS L. PACKER, M.D.,¶¶¶¶¶ ERIC N. PRYSTOWSKY, M.D.,∗∗∗∗∗∗ VIVEK Y. REDDY, M.D.,†††††† JEREMY N. RUSKIN, M.D.,‡‡‡‡‡‡ MAURICIO SCANAVACCA, M.D.,¶¶¶¶¶¶ KALYANAM SHIVKUMAR, M.D.,∗∗∗∗∗∗∗ KYOKO SOEJIMA, M.D.,††††††† WILLIAM J. STEVENSON, M.D.,‡‡‡‡‡‡‡ SAKIS THEMISTOCLAKIS, M.D.,¶¶¶¶¶¶¶ ATUL VERMA, M.D.,∗∗∗∗∗∗∗∗ and DAVID WILBER, M.D.,†††††††† for the Venice Chart members From the ∗Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA; †Cardiovascular Department, Ospedale dell’Angelo, Mestre-Venice, Italy; ‡Cardiac Arrhythmia Service, Stanford University Medical School, Stanford, USA; ¶Department of Cardiac Surgery, Ospedale San Raffaele, Milan, Italy; ∗∗Department of Cardio-Vascular Diseases, CHU de Nancy, Hopital de Brabois, Vandoeuvre-les-Nancy, France; ††Division of Cardiology, Hospital General Gregorio Maranon, Madrid, Spain; ‡‡Department of Cardiology and Angiology, University Hospital of Munster, Munster, Germany; ¶¶Thorax Institute-Cardiology, Hospital Clinic, University of Barcelona, Barcelona, Spain; ∗∗∗Department of Cardiology, The Johns Hopkins Hospital, Baltimore, MD, USA; †††Department of Medicine, Section of Cardiovascular Disease, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; ‡‡‡Department of Electrophysiology, Policlinico San Donato, San Donato Milanese, Italy; ¶¶¶Cardiac and Vascular Sciences, St. George’s Hospital Medical School, London, UK; ∗∗∗∗Cardiology Division, Centro Cardiologico Monzino, Milan, Italy; ††††Cardiac Surgery, University of Western Ontario, London, Canada; ‡‡‡‡Hopital Cardiologique du Haut Leveque, Bordeaux, France; ¶¶¶¶Heart Center, Department of Cardiology, University of Leipzig, Leipzig, Germany; ∗∗∗∗∗Cardiac Morphology Unit, Royal Brompton Hospital, London and Imperial College, London, UK; †††††Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany; ‡‡‡‡‡Department of Medicine, Section of Cardiovascular Disease, University of Pennsylvania, Philadelphia, PA, USA; ¶¶¶¶¶Cardiac Translational and Electrophysiology Laboratory, Saint Mary’s Hospital Complex, Mayo Clinic Foundation, Rochester, NY, USA; ∗∗∗∗∗∗The Care Group, Indianapolis, IN, USA; ††††††Cardiac Arrhythmia Service, Miller School of Medicine, University of Miami, Miami, USA; ‡‡‡‡‡‡Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA; ¶¶¶¶¶¶Heart Institute, University of San Paulo Medical School, San Paulo, Brazil; ∗∗∗∗∗∗∗Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; †††††††Cardiovascular Division, University of Miami Hospital, Miami USA; ‡‡‡‡‡‡‡Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA, USA; ¶¶¶¶¶¶¶Cardiovascular Department, Ospedale dell’Angelo, Mestre-Venice, Italy; ∗∗∗∗∗∗∗∗Cardiology, Southlake Regional Health Center, Toronto, Canada; and ††††††††Department of Cardiology, Loyola University Medical Center, Chicago, IL, USA

The purpose of this Consensus Statement is to provide a state-of-the-art review of the field of catheter ablation of ventricular tachycardia (VT), and to report the findings of a Task Force, convened by the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS) that was charged with defining the indications, techniques, and outcomes of this procedure. This statement summarizes the opinion of the Task Force members based on their own experience in treating patients, as well as a review of the literature. It is directed to all healthcare professionals who treat patients who are considered for catheter ablation of VT. This statement is not intended to recommend or promote catheter ablation of VT. Rather, the ultimate judgement regarding care of a particular patient must be made by the healthcare provider and the patient with consideration of the individual patient characteristics that impact on risks and benefits of the therapy. In writing a ‘consensus’ document, it is recognized that consensus does not mean that there was complete agreement among all Task Force members. We identified those aspects of VT ablation for which a true ‘consensus’ could be identified. Surveys of the entire Task Force were used to identify these areas of consensus. For the purposes of this Consensus Document, we defined a consensus as 70% or greater agreement by the members of this task force. One objective of this document is to improve patient care by summarizing the foundation of knowledge for those involved with catheter ablation of VT. All members of the Task Force, as well as peer reviewers of the document, were asked to provide disclosure statements of all relationships that might be perceived as real or potential conflicts of interest. Disclosures for the members of the task force are given in the Appendix section. Catheter ablation …

The survival of patients with idiopathic dilated cardiomyopathy (IDCM) at III and IV stages of New York Heart Association (NYHA) is decreased in those with a bundle branch block (BBB) compared to those without BBB. Less is known on the prognosis of patients at earlier stages of NYHA and who had a left BBB (LBBB) or right BBB (RBBB). We sought to evaluate the prevalence and the clinical significance of LBBB or RBBB in patients with IDCM and classes I and II of NYHA.Clinical data, noninvasive, and invasive studies were consecutively collected in 310 patients, with IDCM, followed up to 4.8+/-3.7 years.Seventy-six patients (25%) had LBBB, 21 (7%) had RBBB, and 212 had no BBB. Patients with BBB were older than other patients (P0.009). Left ventricular ejection fraction (LVEF) was lower in LBBB than in RBBB and other patients (P0.05). Syncope was more frequent in BBB than in absence (P0.05). Incidence of spontaneous ventricular tachycardia (VT) and atrial fibrillation, VT induction, total cardiac events, and sudden death were similar in the presence or absence of BBB. Deaths by heart failure and heart transplantations tended to be more frequent in BBB than in absence.LBBB was present in 25% of patients with IDCM; RBBB was rare. Patients with BBB were older and had more frequent syncope than patients without BBB; LVEF was lower in LBBB than in RBBB or in absence of BBB. BBB did not increase the risk of spontaneous VT, VT induction, or sudden death, and tended to increase deaths by heart failure and the indications of heart transplantation.

Anatomical guided atrial fibrillation (AF) catheter ablation relies on the assumption that the left atrium reconstruction anatomy (LARA) using a 3D mapping system precisely matches the patient's CT scan anatomy (real anatomy). This study investigates whether this postulation is accurate using CT scan image integration.Thirty consecutive patients (23 men, mean age = 51.9 +/- 9.9 years) with symptomatic drug-refractory paroxysmal (n = 21) or persistent (n = 9) AF underwent a circumferential, 2 x 2, pulmonary vein (PV) radiofrequency (RF) ablation using the CARTOMERGE system. Left atrium (LA) anatomy was first reconstructed and RF design lines drawn on this LARA. After a CT-scan image of the LA was integrated into the 3D system, RF lesions were deployed 10 +/- 5 mm outside the PV ostia (PVO) onto the CT-scan LA surface. The match between the actual RF lines and the RF design lines was analyzed off-line after catheter withdrawal.Circumferential RF design lines were divided into four segments encircling both the right and left PVs. Design segments matched the actual RF segments in a proportion varying from 23% up to 83%. A mean of 2.8 +/- 1.6 segments per patient were inaccurately designed that extended a mean of 3.8 +/- 2.3mm inside the adjacent PV or 6.7 +/- 1.8mm inside the left atrial appendage (LAA). Seven patients (23%) had four or more segments incorrectly designed.Our study reveals the inaccuracy of 3D anatomic guided RF ablation with respect to the LA anatomical structures that could be possibly improved when combined with CT-scan image integration.

Atrial fibrillation (AF) is associated with impaired functional capacity and quality of life and significant morbidity and mortality. The current management approach fails to maintain stable sinus rhythm (SR) in the majority of patients. For many years, guidelines have recommended antiarrhythmic treatment of a first AF episode only if the AF is poorly tolerated, a position that has been reinforced by studies showing no mortality or morbidity advantage of rhythm control over rate control. During the last decade, research has shown mechanisms of self-perpetuation of AF based on electrophysiological and structural remodelling induced by AF itself. There is mounting evidence that 'lone' AF is because of a host of factors, some of which may be easily treatable, such as hypertension, sleep apnoea, and obesity, thus allowing secondary prevention at the time of the first episode of AF. According to these concepts, lack of early intervention could be one of the reasons for long-term failure of maintenance of SR. In this position paper, we propose testing the working hypothesis that if an SR maintenance strategy is selected, treatment of AF should commence at the first-detected episode and should be based on a double strategy of SR restoration and aggressive treatment of associated conditions that promote atrial remodelling.

Background: Long-term prognosis of coronary artery disease (CAD) patients is worsened when stress ischemia persists on treatment, but the relationship with adverse cardiac remodelling had never been investigated. Aim: To analyze changes in blood markers of fibrosis in patients with chronic CAD exhibiting exercise ischaemia. Methods: Circulating markers of collagen: (i) turnover (amino-terminal propeptide of collagen-III [PIIINP]) and (ii) degradation (matrix metalloproteinase 1 [MMP-1]), were obtained in 139 CAD patients referred for exercise 201Tl-SPECT. Results: In the 57 patients who had SPECT-ischaemia, PIIINP was higher (4.3±2.9 μg L−1 vs. 3.1±1.5 μg L−1, p=0.002) and MMP-1 lower (3.8±2.1 μg L−1 vs. 4.7±2.8 μg L−1, p=0.04) than in the 82 patients without SPECT-ischaemia. PIIINP was independently related to LV volume, SPECT-ischaemia and age, whereas MMP-1 was related to current treatment with ACEI and β-blockers (p

Background— This study aims to assess the incidence and clinical relevance of slow ventricular tachycardia (VT) and the effectiveness and/or deleterious effects of antitachycardia pacing in slow VT in implantable cardioverter-defibrillator recipients. Methods and Results— This multicenter prospective randomized study included 374 patients (326 men) without prior history of slow VT (148 bpm), and a ventricular fibrillation zone. Patients were randomized to a treatment group (n=183) with therapy activated in the slow VT zone or a monitoring group (n=191) with no therapy in the slow VT zone. During follow-up (11 months), 449 slow VTs occurred in 114 patients (30.5% slow VT incidence); 181 VTs (54 patients) occurred in the monitoring group; 3 were readmitted to the hospital; and lightheadedness and palpitations occurred in 4 and 250 (60 patients) in the treatment group treated by antitachycardia pacing (89.8% success rate) and shock delivery (n=2). There were 10 crossovers from the monitoring to treatment group and 3 crossovers from the treatment to monitoring group ( P =0.09). Quality of life scores were not different between groups. Conclusions— Slow VT incidence (

This article reviews the arrhythmia detection criteria currently available in dual-chamber implantable cardioverter defibrillators (ICDs), and describes the implementation and performance of various detection algorithms. Nearly all criteria implemented in single-chamber devices appear to have been included in dual-chamber ICDs. However, two different strategies can be distinguished: the first adds dual-chamber inhibition criteria to a single-chamber detection configuration; the second is a new approach entirely based on a dual-chamber detection scheme. Despite widely available clinical data, an analysis of the implemented detection indexes, arrhythmia characteristics (induced vs spontaneous, minimum duration), device programming (detection rate, programme maintenance and tuning during follow-up), and different storage capabilities among various ICD models, leaves the results of these studies ultimately ambiguous. New algorithms are under study, but only protocols using a single set of arrhythmias and the same programming for all devices may allow relevant comparisons of the performances of detection algorithms. Furthermore, a criterion is required to distinguish reliably between haemodynamically stable and unstable tachycardias, not simply based on rate, but including the underlying cardiac function.

Background — The reentrant mechanism of postinfarct ventricular tachycardia (VT) has been documented by surgical mapping analysis, but little is known about postinfarct VT circuits and the characteristics of their related protected isthmus with the use of 3D catheter mapping systems. Methods and Results — A 3D electroanatomic mapping was performed in 21 patients with well-tolerated, postinfarct, sustained VT. In total, 33 episodes of tachycardia (mean cycle length 432±74 ms) were induced and mapped. Complete maps demonstrated macroreentrant circuits with 1 loop (n=8) or 2 loops (n=25) rotating around a protected isthmus bounded by 2 approximately parallel conduction barriers that consisted of a line of double potentials, a scar area, or the mitral annulus. A total of 26 critical isthmi were identified for the 33 VTs mapped, with the same isthmus being shared by 2 to 4 different tachycardic morphologies in 5 patients. On average, isthmi were 31±7 mm long (ranging from 18 to 41 mm) and 16±8 mm wide (ranging from 6 to 36 mm) and harbored diastolic electrograms. The isthmus axis was oriented parallel to the mitral annulus plane in perimitral circuits and perpendicular to the mitral annulus plane in all other circuits. Linear radiofrequency ablation performed across the most accessible part of the isthmus prevented the recurrence of tachycardia in 19 patients (90%) with a follow-up at 16±8 months. Conclusions — Detailed 3D electroanatomic mapping is helpful in reconstructing postinfarct VT circuits and in defining the characteristics of their related protected isthmi. The wide range of isthmus width values supports the need of linear radiofrequency lesions to eliminate the reentrant substrate of postinfarct VTs.

Arrhythmia Discrimination by ICD.Introduction: Despite technologic developments, accurate discrimination of ventricular tachyarrhythmia from rapid rhythms of nonventricular origin remains a challenge. We sought to examine the sensitivity and specificity of a dual-chamber arrhythmia detection algorithm, the PARAD algorithm, incorporated in a dual-chamber implantable cardioverter defibrillator, the Defender (ELA Medical). Methods and Results:All detailed tachycardia episodes (i.e., with stored atrial and ventricular channel markers and electrograms) retrieved from the Holter memory of the device were analyzed from 95 patients (86 men and 9 women; age 62 ± 12 years) implanted with the Defender with the algorithm programmed at nominal settings. Over a follow-up of 15 ± 8 months, 559 detailed sustained tachycardia episodes detected in the tachycardia zone were gathered in 62 patients. Of the 300 ventricular tachycardia (VT) episodes, 298 were appropriately classified as VT by the algorithm. Of the 259 supraventricular tachycardia (SVT) episodes, 231 were appropriately classified as SVT. In 8 patients, 28 episodes of SVT were misclassified as VT: 25 atrial fibrillation episodes (6 patients), 2 sinus tachycardia (1 patient), and 1 atrial tachycardia. Calculated sensitivity and specificity were 99.3% and 89.2% on a per episode basis and 99.8% (95% confidence interval: 97.8 to 100) and 91.6% (95% confidence interval: 86.0 to 97.3) on a per patient basis, respectively. Conclusion: In this selected population of patients, the PARAD algorithm was safe and reliable for detection of a wide spectrum of tachyarrhythmias. Its specificity was high, particularly with respect to sinus tachycardia detection, but it must be improved with respect to detection of atrial fibrillation.

Patients with hypertrophic cardiomyopathy (HCM) present unusual myocardial mechanics. The aim of this study was to assess the impact of hypertrophy on global and regional two-dimensional (2D) strain derived from both tomographic images (2D/2D) and volumetric image acquisition (2D/three-dimensional [3D]) in patients with HCM compared with control subjects.Comprehensive resting 2D and 3D echocardiography was performed in 40 patients with HCM and in 53 control subjects, with comparable distributions of age, gender, and left ventricular (LV) ejection fraction. LV global and segmental measurements of all 2D/2D and 2D/3D peak strain components (global and segmental longitudinal strain, global and segmental circumferential strain, global and segmental radial strain, and global and segmental area strain) and 3D indexed LV end-diastolic myocardial mass were obtained from all patients. LV wall thickness was assessed in short-axis views and classified in four quartiles (10.5, 10.5-13.0, 13.0-16.5, and16.5 mm).The reproducibility of 2D/3D strain was similar or greater and more consistent for all components compared with 2D/2D strain analysis. There was a significant correlation between 3D LV end-diastolic mass and all 2D/3D strain components (P .05). Two-dimensional/3D global circumferential strain had the strongest association with 3D LV ejection fraction (r = 0.50, P = .001). For segmental deformation, patients with HCM had lower longitudinal deformation whatever the LV wall thickness, whereas circumferential function was increased in nonhypertrophied and poorly hypertrophied segments compared with control subjects.Two-dimensional/3D strain is a reliable technique to assess myocardial deformation. Myocardial mass is related to 2D/3D strain components in patients with HCM. Circumferential deformation, compared with longitudinal deformation, seems to be the main component of the maintenance of systolic function in HCM.

Know the indications of these new drugs, and respect them. Do not confuse easiness of administration and absence of precautions. Renal function: a key parameter before and during treatment. Know when to use a low-dose drug regimen. Cardioversion: lack of safety evidence for some drugs. Drug interactions: beware of P-glycoprotein and cytochrome P450.

Last year was the 20th anniversary of the first defibrillator implantation in a human being. Since then, the number of new defibrillator implants has gradually increased following an exponential curve. In 1998, nearly 50 000 new ICD implants were carried out worldwide. This tremendous increase was due to technological improvements in the device and the effectiveness of ICD therapy. Technological improvements in devices and leads included a gradual reduction in the size of the device, the introduction of the endocardial approach in 1988, the biphasic waveform and antitachycardia pacing in 1991, pectoral implantation in 1995, inclusion of DDD pacing in 1996 and finally, inclusion of DDDR and also atrial defibrillation in 1998. Efficacy assessment started with observational studies. In 1985, FDA approval for ICD implantation was obtained. Results of prospective randomized studies, which assessed the effectiveness of ICDs, were obtained in the late 1990s. The first reported trial was essentially an analysis of cost-effectiveness, which compared ICD implantation as first-choice therapy vs conventional strategy starting with antiarrhythmic drugs in postinfarct sudden death survivors. If drugs failed, the patient was treated with endocardial resection or a late defibrillator implant. The cost-effectiveness ratio, defined as costs per day of life, was significantly in favour of early ICD implantation. However, because the number of patients was relatively small, total mortality showed only a trend in favour of early ICD implantation.

Accessory Pathway Localization. Introduction: The purpose of this study was to evaluate the accuracy and limitations of published algorithms using the 12-lead ECG to localize AV accessary pathways (APs). Methods and Results: The 11 relevant algorithms found in the literature (MEDLINE database and major scientific sessions) were tested on a series of 266 consecutive patients who successfully underwent radiofrequency catheter ablation of a single overt AV AP. The positive predictive values (PPV) of the algorithms in applicable patients were significantly lower for algorithms with > 6 accessory location sites (40.6%± 10.9% vs 61.2%± 8.0%; P < 0.03) and show a tendency for algorithms not relying on delta wave polarity but on QRS polarity only (36.6%± 11.2% vs 52.3%± 13.1%; P = 0.09). The PPV in applicable patients is related to the AP location (P < 0.001) and ranked from the highest to the lowest as follows: left lateral (mean PPV = 86.3%), posteroseptal (mean PPV = 65.2%), right anteroseptal (mean PPV = 45.2%), and right posterolateral (mean PPV = 23.4%). Conclusion: Our study suggests that the accuracy of algorithms relying on the 12-lead ECG depends on AP locations as defined in the algorithms and on the number of AP sites. The accuracy tends to be lower when delta wave polarity is not included in the algorithm's architecture. This should be considered when using these algorithms or when building new ones.

1. In patients with dilated cardiomyopathy, abnormal myocardial blood flow may contribute to poor myocardial function. 2. The aim of this study was to investigate the possible contribution of abnormal myocardial blood flow to the limitation of exercise capacity in patients with dilated cardiomyopathy. 3. Coronary flow reserve was assessed in 16 patients with dilated cardiomyopathy and 9 matched normal control individuals. All participants had angiographically normal coronary arteries. At rest and after dipyridamole infusion (0.56 mg/kg intravenously), peak systolic and diastolic coronary flow velocities were measured in the proximal left anterior descending coronary artery using transoesophageal pulsed Doppler echocardiography, guided by colour flow imaging. Coronary flow reserve was calculated as the ratio of hyperaemic to basal diastolic and systolic peak coronary flow reserve. 4. Baseline diastolic and systolic coronary flow velocities were significantly higher in patients (50 ± 6 and 30 ± 4 cm/s respectively) compared with control individuals (37 ± 3 and 20 ± 1 cm/s respectively) (mean ± S.E.M.) (P < 0.05). Diastolic and systolic peak coronary flow reserve were significantly lower in patients (1.60 ± 0.14 and 1.40 ± 0.09 respectively) compared with control individuals (2.89 ± 0.15 and 2.17 ± 0.17 respectively) (P < 0.001). Although peak Vo2 and exercise time were significantly lower in patients compared with control individuals, coronary flow reserve did not correlate to exercise capacity in patients with dilated cardiomyopathy. 5. These results confirm the abnormalities of coronary flow reserve previously observed in patients with dilated cardiomyopathy, but suggest that such abnormalities do not contribute to the limitation of exercise capacity in these patients.

The radial artery compliance may be paradoxically increased in untreated arterial hypertension. However, the effect of blood pressure normalization on the radial artery compliance is not well known. We performed a cross-sectional study in order to investigate the effects of blood pressure control on the radial artery diameter and compliance (echotracking and digital photoplethysmography) by comparing these variables in a group of untreated hypertensive patients and in another group of adequately treated hypertensive patients as well as in a group of healthy normotensive subjects. All groups were sex- and age-matched. Radial artery internal diameter was increased in both untreated hypertensive patients and effectively treated hypertensive patients comparatively to controls. Cross-sectional compliance and volumic distensibility were not different between groups. As compared to controls (2.85 +/- 0.39 x 10(-3) mm2 x mm Hg(-1) and 0.42 +/- 0.05 x 10(-3) mm Hg(-1)), isobaric (100 mm Hg) compliance and distensibility were significantly increased in untreated hypertensive patients (4.46 +/- 0.44 and 0.65 +/- 0.07, P < .01) but not significantly different in treated hypertensive patients (3.19 +/- 0.33 and 0.45 +/- 0.04, P = NS). The results of this cross-sectional study suggest that compliance abnormalities of the radial artery, but not internal diameter changes may be reversed by effective therapeutic control of blood pressure in arterial hypertension.

International audience; BACKGROUND:Most postinfarct ventricular tachycardias (VTs) are sustained by a reentrant mechanism. The "protected isthmus" of the reentrant circuit is critical for the maintenance of VTs and the target for catheter ablation. Various techniques based on conventional electrophysiology and/or detailed three-dimensional (3D) reconstruction of the VT circuit are used to unmask this isthmus.OBJECTIVE:The purpose of this study was to assess pace-maps (PMs) to identify postinfarct VT isthmuses. We hypothesized that an abrupt change in paced QRS morphology may be used to identify a VT isthmus and be targeted for successful ablation.METHODS:High-density 3D PMs were matched to the subsequent 3D endocardial reentrant VT activation mapping in 10 patients (8 men; age 70.7 ± 10.8 years) who underwent successful postinfarct VT ablation. At each pacing site in a given patient, the 12-lead ECG recorded during pacing was compared to that of VT, with the resulting matching percentage (up to 100% for perfect matches) allocated to this point to generate color-coded PMs.RESULTS:With respect to VT isthmuses, the best percentages of matching were found in the exit zones and isthmus exit part (89% ± 8% and 84% ± 7%, respectively) and the poorest adjacent to scar border in the outer entrance zones (23% ± 28%), in the entrance zones (39% ± 34%), and in the entrance part of the isthmus (32% ± 26%). The color-coded sequence (from the best to the poorest matching sites) on the PMs revealed figure-of-eight pictures matching the VT activation time maps and identifying VT isthmuses.CONCLUSION:Pace-mapping is useful for unmasking VT isthmuses in patients with well-tolerated postinfarct endocardial reentrant VTs.

Survey on Atrial Fibrillation Ablation Background Atrial fibrillation (AF) ablation is widely adopted. Our aim was to conduct a prospective multicenter survey to verify patients' characteristics, approaches, and technologies adopted across Europe. Methods and Results A total of 35 centers in 12 countries actively participated in the study and 940 patients (median age 60 years) were enrolled. AF was paroxysmal, persistent, and long-lasting persistent in 52.4%, 36%, and 11.6% of patients, respectively; 95.5% of patients were symptomatic and 91.4% were refractory to antiarrhythmic therapy. Redo procedures were performed in 20.9%. Pulmonary vein isolation (PVI) emerged as the cornerstone of ablative therapy and has been performed in 98.7% of procedures, with confirmation of PVI in 92.9% of cases. The ablation of nonparoxysmal AF was not generally limited to isolating the PVs and several adjunctive approaches are adopted, particularly in the case of long-lasting persistent AF. Linear lesions or elimination of complex fractionated atrial electrograms were more frequently added. Circular mapping catheters and imaging techniques were seen to be used in about two-thirds of cases. Radiofrequency energy was delivered through open irrigated catheters in 68% of cases. Conclusions European centers are largely following the recommendations of the guidelines and the expert consensus documents for AF ablation. AF ablation is mainly performed in relatively young patients with symptomatic drug refractory AF and no or minimal heart disease. Patients with paroxysmal AF are the most frequently treated with a quite uniform ablative approach across Europe. A less standardized approach was observed in nonparoxysmal AF patients.

Background— The occurrence of ventricular tachycardia (VT) after myocardial infarction is associated with poorer prognosis. In such patients, implantable cardioverter-defibrillators are recommended. Catheter ablation of VT is currently recommended only as an adjunctive therapy. Whether a successful VT ablation alone might be a viable strategy in some of these patients, however, remains unknown. The aim of the present study was to evaluate this strategy. Methods and Results— Between January 2002 and December 2011, 189 patients with cardiomyopathy underwent 259 VT ablations in our center. Forty-five patients (mean age, 65.2±9.6 years; 91% men) with a history of myocardial infarction and mean left ventricular ejection fraction of 39.7±9.7% matched the study criteria and were included in this analysis. Acute success was obtained in 40 of 45 patients (88.9%). During a follow-up, on the basis of our stepwise algorithm (using acute success, repeat electrophysiological study, and recurrence of VT), 19 of 45 patients (42.2%) underwent implantable cardioverter-defibrillators implantation. During a median follow-up of 4.5 (interquartile range, 2.1–7.0) years, all-cause mortality occurred in 14 of 45 patients (31.1%). Using multivariate Cox regression analysis, age (hazard ratio, 1.13; 95% confidence interval, 1.03–1.22; P =0.007) was the only independent predictor of mortality, whereas implantable cardioverter-defibrillators implantation was not (hazard ratio, 0.54; 95% confidence interval, 0.18–1.64; P =0.28) Conclusions— Our results suggest that a stepwise approach to the management of VT with ablation as a first-line treatment in postinfarct patients presenting with VT might be a reasonable option. Further studies are required to confirm these results.

We investigated the relationship between exercise capacity and the level of neurohormonal activation at rest and during exercise in patients with various degrees of severity of chronic heart failure. We performed exercise testing with measurements of peak oxygen consumption (pVo2) and blood sampling at rest and at peak exercise in eight patients with moderate heart failure (pVo2 = 17 +/- 0.4 ml/kg/min) (mean +/- S.E.M.) and eight patients with severe CHF (pVo2 = 9 +/- 1 ml/kg/min). None of the patients was taking angiotensin converting enzyme inhibitors or beta-blockers. Plasma levels of atrial natriuretic peptide, cGMP, arginine-vasopressin, renin, angiotensin II, epinephrine and norepinephrine increased significantly (P < 0.01), from rest to peak exercise, in all patients. Among all the studied neurohormonal factors, only atrial natriuretic peptide levels at rest as well as at peak exercise, in patients with severe heart failure were correlated significantly to pVo2 (r = -0.77, P = 0.04; r = -0.85, P = 0.01, respectively) and to exercise duration (r = -0.72, P = 0.05; r = -0.79; P = 0.03, respectively). The relationship between plasma levels of atrial natriuretic peptide and of cGMP was shifted downward in the more severe patients suggesting the loss of biological activity of atrial natriuretic peptide.

The viscoelastic, muscular and endothelial components of the vessel wall may be altered in patients with congestive heart failure (CHF). In order to investigate the relative contribution of each of these components to the peripheral vascular mechanisms of the disease, we have studied post-ischemic (endothelial-dependent) and post-nitroglycerin (endothelial-independent) vasodilatation as well as the response to cold pressure test and the geometry and compliance of the radial artery using a non-invasive echotracking method coupled to digital photoplethysmography. Thirty-nine patients with congestive heart failure (ejection fraction = 28 +/- 2%) were compared to age- and sex-matched healthy controls. Baseline therapy was unchanged during the study. In congestive heart failure patients, cross-sectional compliance and volumic distensibility were greater (P0.05) but isobaric compliance which is independent of blood pressure value was unchanged. Post-ischemic and post-nitroglycerin vasodilatation were lower (7 +/- 1 vs. 11 +/- 1%, P0.01 and 6 +/- 1 vs. 14 +/- 2%, P0.001, respectively) and both of the arterial diameter and pressure responses to cold pressor test were blunted (-5 +/- 1 vs. -8 +/- 1%, P = 0.058 and 6 +/- 3 mmHg vs. 13 +/- 2 mmHg, P0.01, respectively) in congestive heart failure. These changes were similar in primary and ischemic congestive heart failure, suggesting that they are more likely related to common neuro-hormonal factors rather than to an atherosclerotic process.

Objectives. This study sought to determine whether the reopening of the infarct-related vessel is related to clinical characteristics or cardiovascular risk factors, or both. Background. In acute myocardial infarction, thrombolytic therapy reduces mortality by restoring the patency of the infarct-related vessel. However, despite the use of thrombolytic agents, the infarct-related vessel remains occluded in up to 40% of patients. Methods. We studied 295 consecutive patients with an acute myocardial infarction who underwent coronary angiography within 15 days (mean [±SD] 6.7 ± 3.2 days) of the onset of symptoms. Infarct-related artery patency was defined by Thrombolysis in Myocardial Infarction trial flow grade ≥ 2. Four cardiovascular risk factors—smoking, hypertension, hypercholesterolemin and diabetes mellitus—and eight different variables—age, gender, in-hospital death, history of previous myocardial infarction, location of current myocardial infarction, use of thrombolytic agents, time interval between onset of symptoms, thrombolytic therapy and coronary angiography—were recorded in all patients. Results. Thrombolysis in current smokers and anterior infarct location on admission were the three independent factors highly correlated with the patency of the infarct-related vessel (odds ratios 3.2, 3.0 and 1.9, respectively). In smokers, thrombolytic therapy was associated with a higher reopening rate of the infarct vessel, from 35% to 77% (p < 0.001). Nonsmokers did not benefit from thrombolytic therapy, regardless of infarct location. Conclusions. These observational data, if replicated, suggest that in patients with acute myocardial infarction, thrombolytic therapy may be most effective in current smokers, whereas non-smokers and ex-smokers may require other management strategies, such as emergency percutaneous transluminal coronary angioplasty.

The aim of our study was to investigate the contribution of physical deconditioning in skeletal muscle metabolic abnormalities in patients with chronic heart failure (CHF). Phosphate metabolism was studied in the leg muscle at rest and during exercise by using phosphate 31 nuclear magnetic resonance spectroscopy in a group of 14 patients with New York Heart Association class II and III CHF and left ventricular ejection fraction

Aims Two-dimensional echocardiography often reveals abnormal left ventricle (LV) lateral wall kinetics in patients presenting with mitral valve prolapse (MVP). However, relations between MVP and LV deformation are not clearly established. The aim of this study was to assess and quantify mitral valve chordae, leaflets, and LV myocardial interactions using speckle tracking echocardiography (STE). Methods and results Using STE-derived longitudinal strain curves, LV peak longitudinal strain (PLS, %), post-systolic index (PSI), and pre-stretch index (PST) were analysed in 100 patients with MVP and normal LV ejection fraction. Global, regional, and segmental values were compared according to mitral regurgitation severity and MVP location. Twenty healthy subjects served as control patients. There was no significant difference among control and MVP group for global and regional PLS (-23.7 ± 3.2 vs. -23.1 ± 2.2). In contrast, patients with MVP had significantly higher values of global PST (3.2 ± 4.1 vs. 1.3 ± 1.2; P = 0.01) and global PSI (3.2 ± 0.4 vs. 1.7 ± 1.1; P = 0.05) compared with controls, located mainly in the lateral wall and basal segments. Both anterior and posterior MVPs were responsible for PSI in basal inferior segments and PST in anterior ones. Mid-wall segmental deformation pattern changes were mainly observed at the level of the segments adjacent to the papillary muscle. Conclusion This study supports the hypothesis that pathological early-systolic shortening and late systolic, post-systolic deformation are attributed to an increased interaction between wall deformation and mitral valve events in patients with MVP. STE is a useful tool in the assessment of interplays between MV leaflets and myocardium and helps to demonstrate changes in temporal pattern of myocardial deformation.

The number of scar-related ventricular tachycardia (VT) ablation procedures is increasing worldwide. This is certainly due to the ever growing number of patients implanted with an implantable cardioverter defibrillator in whom an ablation procedure may be required to better control the ventricular arrhythmia burden, but is also likely related to our better understanding of the arrhythmias mechanisms as well as the improvement of the mapping techniques during the last 15 years. Most VTs, especially those arising after myocardial infarction, depend on a critical isthmus. Defining precisely the critical isthmus of postinfarct VT may be challenging, particularly when the arrhythmia is poorly tolerated. In the literature, there are extensive data concerning the value of conventional electrophysiological techniques, especially entrainment mapping in association with postpacing interval measurements, regarding the identification of postinfarct VT isthmuses. There are, however, other--sometimes emerging--approaches to image critical postinfarct VT channels. We have summarized these, reviewing data from the published literature as well as our own experience.

This French study was set up to collect perceptions of general practitioners (GPs), cardiologists and patients on anticoagulation therapy with vitamin K antagonists (VKA) in the management of thromboembolic risk in atrial fibrillation (AF).This is a prospective survey conducted in France, between July 1 and August 7 2011, on a sample defined to obtain a sufficient number of patient files of 133 physicians, divided into 65 cardiologists and 68 GPs.Three hundred and ninety-four patients on VKA and 130 patients not receiving VKA were included in this study. For more than one in three patients, AF was diagnosed incidentally in a medical consultation for another reason. In addition, 15% and 23% of diagnoses of FA were performed after hospitalization for stroke or TIA by cardiologists and GPs, respectively. According to the patient, the doctor contacted first is a GP (52% for the GP vs. 35.5% for the cardiologist), but they state that the diagnosis was made mainly by a cardiologist (63% for the cardiologist vs. 27% for the GP). In 78% of cases, cardiologists are initial prescribers. A CHADS2 score of 0 was found in 23% of patients not receiving VKA and in 11% of patients on VKA. A CHADS2 score superior or equal to 2 is significantly more frequently found in patients with paroxysmal AF. Concerning the monitoring of the patient, GPs ensure mainly monitoring of INR. In terms of compliance, according to doctors, their patients systematically take their treatment in 91% of cases. However, by interviewing patients, 60% of non-compliant patients are considered compliant by their physician.This study has achieved an overview of anticoagulation treatment in AF, in France. The initiation is mainly ensured by the cardiologist and the monitoring by the GP. Assessments between cardiologists and GPs are relatively similar, however, it appears that anticoagulation treatment is under-prescribed for the patients at risk.

Background Implantable cardioverter-defibrillators (ICDs) remain the treatment of choice for the prevention of life-threatening arrhythmias. However, many patients with ICDs require additional antiarrhythmic therapy to reduce the morbidity associated with recurrent arrhythmia-triggered ICD interventions. Objective Our study aimed to evaluate the safety and efficacy of celivarone in reducing these interventions. Methods A total of 153 eligible ICD recipients were randomized to receive either placebo or celivarone 100 or 300 mg once daily for 6 months. The primary end point was the prevention of arrhythmia-triggered ICD therapies. Results Fewer ventricular tachycardia and ventricular fibrillation episodes were observed in the 300-mg celivarone group than in the placebo group, with a relative risk reduction of 46%, which was not statistically significant. The analysis of all-cause shocks showed a trend toward a decreased number of events in the celivarone 300-mg group. A post hoc analysis of the primary end point in a subgroup of patients in the celivarone 300-mg group, who had received ICD therapy within 1 month of randomization, showed a significant benefit ( P = .032). Celivarone was not associated with an increased risk of torsades de pointes , thyroid dysfunction, or pulmonary events. More heart failure events were reported in the celivarone groups than in the placebo group, but the difference was not statistically significant. Conclusion Celivarone tends to reduce ventricular tachycardia–/ventricular fibrillation–triggered ICD therapies. This effect was not statistically significant. There was a trend toward greater efficacy in the 300-mg group, especially in patients undergoing ICD therapy within 30 days prior to randomization. Overall, celivarone was well tolerated.

Several studies of phosphorus 31 (31P) magnetic resonance spectroscopy (MRS) have demonstrated the presence of skeletal muscle metabolic abnormalities during exercise in patients with chronic heart failure (CHF). We studied the contribution of these abnormalities to the limitation of exercise capacity in CHF. In 25 patients (age 57 +/- 2 years, left ventricular ejection fraction [LVEF] 28% +/- 1.6%, peak oxygen consumption (VO2) 16 +/- 1.2 ml/kg/mm) (mean +/- SEM), we studied the calf muscle at rest and during plantar flexion with 31P MRS. The phosphocreatine (PCr) depletion rate was significantly negatively correlated to peak VO2 (r = -0.62, p = 0.001) but not to LVEF. Muscle pH was correlated with the inorganic phosphorus (Pi)/PCr ratio (r = -0.69, p = 0.0001) and with the PCr/adenosine triphosphate beta (ATP beta) ratio (which negatively relates to adenosine diphosphate [ADP] concentration) (r = 0.65, p = 0.00001). Although muscle ATP (ATP/sum of phosphorus [sigma P] remained stable, in 8 patients ATP/sigma P decreased significantly (-15% +/- 4%, p = 0.0002). In this ATP-depleted group, peak VO2 was significantly lower than that of the nondepleted group and PCr depletion more rapid, whereas LVEF did not differ. Skeletal muscle metabolic abnormalities in CHF contribute markedly to the alteration of exercise capacity. Rapid PCr depletion and muscle acidosis are the most relevant abnormalities. ATP depletion and excessive increase in ADP during exercise may contribute further to exercise limitation specifically in patients with more marked CHF.

Previous invasive studies have suggested that coronary flow reserve is impaired in patients with left ventricular hypertrophy (LVH) and symptoms of ischemia. We tested whether transesophageal Doppler, a semiinvasive technique, can detect altered characteristics of baseline coronary blood flow velocity in such patients. Thirty patients with LVH (hypertrophic cardiomyopathy in 4, aortic stenosis in 17, hypertension in 9) were studied. Fourteen patients had asymptomatic LVH. Sixteen patients had clinical symptoms of ischemia with angiographically normal epicardial coronary arteries. Ten subjects with no cardiovascular disease were studied as a control group. Peak diastolic and systolic coronary flow velocities were recorded in the proximal part of the left anterior descending artery (LAD) with the use of pulsed Doppler guided by color flow imaging. Patients with symptomatic LVH had higher diastolic peak coronary flow velocity (81 +/- 10 cm/sec, p = 0.0001) compared with normal subjects (41 +/- 8 cm/sec) and patients with asymptomatic LVH (44 +/- 8 cm/sec). In patients with asymptomatic LVH the diastolic coronary flow velocity/indexed ventricular mass ratio was lower (0.28 +/- 0.09 cm/gm/m2, p = 0.0001) compared with symptomatic patients (0.52 +/- 0.12 cm/gm/m2) and compared with controls (0.47 +/- 0.16 cm/gm/m2). Patients with symptomatic LVH but no aortic stenosis also had higher peak systolic coronary flow velocity (38 +/- 9 cm/sec) compared with the other groups (p = 0.0001). In the group of patients with aortic stenosis a significant inverse linear relation was found between peak systolic coronary flow velocity and peak pressure gradient (r = -0.60, p 0.01). In conclusion, patients with symptomatic LVH have abnormally high baseline coronary flow velocities resulting in magnified intimal shear stress. Because flow velocity equals flow/vessel cross-sectional area, it is suggested that high coronary flow velocities in patients with symptomatic LVH result from both augmented coronary flow and failure of the vessel to enlarge commensurately with the increase in LV mass (relative functional stenosis). In patients with aortic stenosis, peak systolic coronary flow velocity appears to be influenced by transvalvular pressure drop.

Celivarone in Atrial Fibrillation/Atrial Flutter. Introduction: Celivarone, a new noniodinated benzofuran derivative pharmacologically related to dronedarone and amiodarone, has been shown to have antiarrhythmic properties at a molecular level. The purpose of the 2 trials presented here (MAIA and CORYFEE) was to assess celivarone efficacy in the maintenance of sinus rhythm postcardioversion and for the conversion of atrial fibrillation (AF)/atrial flutter (AFL). Methods and Results: In the MAIA trial, 673 patients with AF/AFL recently converted to sinus rhythm were randomly assigned to receive 50, 100, 200, or 300 mg once-daily dosing of celivarone; 200 mg daily of amiodarone preceded by a loading dose of 600 mg for 10 days; or placebo. At 3 months’ follow up, no significant difference was observed in time to AF/AFL relapse among the various celivarone groups and placebo. However, fewer symptomatic AF/AFL recurrences were observed in the lower-dose celivarone groups (26.6% for celivarone 50 mg [P = 0.022] and 25.2% for celivarone 100 mg [P = 0.018] vs 40.5% for placebo at 90 days). Fewer adverse events were observed with the use of celivarone and placebo than amiodarone. In the CORYFEE study, 150 patients with AF/AFL were randomly assigned to once-daily celivarone dosing of 300 or 600 mg, or placebo, for a 2-day treatment period. There was no significant difference in the rate of spontaneous conversion to sinus rhythm between the treatment and control groups. Conclusions: In these studies, celivarone does not appear to be efficacious in the maintenance of sinus rhythm in AF/AFL patients or for the conversion of AF/AFL patients. (J Cardiovasc Electrophysiol, Vol. 23, pp. 462-472, May 2012)

Radiofrequency ablation has became a validated therapeutic technique for symptomatic drug refractory atrial fibrillation (AF). Cardiac computed tomography (CT) is used to evaluate left atrial (LA) anatomy in order to improve AF ablation. The analysis of noncardiac structures during cardiac CT may identify clinically significant incidental findings (IFs). The objective of this study was to determine the prevalence of IF in patients undergoing AF catheter ablation.Between February 2008 and March 2010, all patients planned for a first procedure of AF or LA tachycardia (LAT) ablation underwent a cardiac CT scan and were retrospectively included in this study. Extracardiac IFs were considered to be present if an abnormality was identified without previous clinical suspicion or known disease.Two hundred and fifty patients (55.2 ± 9.6 years of age, 82.4% men) were enrolled (133 paroxysmal, 43 persistent, 58 permanent AF, and 16 LAT). Fifty-eight patients (23.2%) had a total of 76 IFs. Patients with IF were significantly older (59.5 ± 8.2 vs 53.8 ± 9.7 years old, P0.001). No relationship existed between the type of arrhythmia and IF existence. The majority of IFs were pulmonary (50%), with 15.8% of pulmonary emphysema. Two cases of lung cancer and of pulmonary fibrosis, 15 mediastinal adenopathies, and three congenital coronary arteries anomalies were found.Cardiac CT scan is a useful tool to evaluate LA morphology before AF ablation. However, as a considerable prevalence of IF was found in our study, extracardiac structures should be routinely analyzed to detect unknown conditions, which could require specific management.

Implantable cardioverter-defibrillator (ICD) malfunctions sometimes need recall. Despite the increasing number of device implantation, ICD recalls and advisories' impacts have been little studied. The aim of this study was to determine the rate of ICD generator advisory in our center and to examine its clinical and financial implication.We analyzed weekly Food and Drug Administration (FDA) Enforcement Reports issued between January 2000 and December 2008 to identify all advisories involving ICD generators and leads. We performed a retrospective analysis of all implanted patients affected by an advisory in our Cardiology department.During the 8 years of the study period, 13 advisories were issued for generators and one for leads, leading to a total number of 278 of 1,051 (26.4%) device with recall alerts, divided into 196 generator failures and 82 lead failures. Premature generator replacement was performed in 11 patients, whereas nine patients underwent lead replacement. There was no major complications attributable to advisory device replacement, and minor complications occurred only in one patient (lead extraction failure). Recalls accounted for 593 extra outpatient visits with a mean number of 2.20 ± 2.19 per patient. The total estimated cost of the device advisories in our population was 334,528 €.ICD recalls and safety alerts frequently occur in ICD recipients and tend to increase in number and rate. Although potentially serious, they do not appear to be associated with substantial complications. Financial implications are important.

Aims Atrial fibrillation (AF) is not always perceived as a serious health threat, but is the most common sustained arrhythmia, with a major impact on morbidity, mortality, and patient quality of life (QoL). A survey was undertaken to examine the level of understanding, perception, and attitudes of the cardiovascular risks associated with AF. Methods and results The AF AWARE group (an international coalition of organizations with an interest in AF) conducted an international quantitative survey in 11 countries in 2009, to investigate patients' ( n = 825) and cardiologists' ( n = 810) perceptions of AF, preferences for communicating information on AF and burden of AF. Both patients and physicians considered AF life-threatening (55 and 43%, respectively). Physicians were more concerned about the risk of stroke and hospitalizations than patients, whereas patients were most concerned about death risk. One in four patients felt unable to explain AF and >33% were worried or fearful about their disease. Many physicians (51%) wanted more patient information with >60% viewing available information as poor/difficult to find. Hospital specialists and GPs were identified as key information sources for patients. Most patients (83%) reported symptoms, yet 75% claimed to be satisfied with AF therapies. Atrial fibrillation patients, often with associated diseases, made an average of nine visits per year to their doctors, who consider AF difficult and time consuming to manage. Patients and physicians rated the QoL impact of AF as moderate to high. Conclusions A comprehensive international patient and professional information and support programme on AF is needed to improve management and consequently health outcomes.

We aimed to evaluate the long-term clinical outcomes among patients with peripheral arterial disease (PAD) after coronary artery bypass grafting. We studied 589 consecutive patients who had undergone isolated coronary artery bypass grafting from January 2003 to June 2005 at our university hospital. The effect of PAD was assessed by comparing the 2-year follow-up data from 2 groups of patients: 243 patients with and 346 without PAD. A large systematic atherosclerosis screening was performed, including cerebrovascular disease, lower extremity artery disease, and abdominal aorta disease and its branches. PAD was defined as a history of treated atherosclerotic disease and significant atherosclerotic stenosis on screening. Patients with PAD were significantly older (70 +/- 9 vs 64 +/- 11 years, p0.001) and were more often men (p = 0.04) than those without PAD. They had a greater incidence of hypertension (p = 0.002), chronic renal dysfunction (p0.01), chronic pulmonary disease (p = 0.005), and a history of coronary artery disease (p = 0.03). No significant difference was noted between the 2 groups with regard to the left ventricular ejection fraction. The 2-year cumulative survival rate was 76.6% for patients with PAD and 94.1% for those with isolated coronary disease (p0.001). In conclusion, after adjusting all significant variables, the presence of PAD appeared as an independent predictive factor for all-cause mortality (adjusted hazard ratio 3.2, 95% confidence interval 1.8 to 5.7, p = 0.001).

ECG loop recorders have a retrospective (loop) memory which continuously records and deletes the patient's ECG. They include a patient-activation function that allows the patient to activate ECG storage as a result of symptoms and an auto-activation feature that allows the capture of arrhythmic events without relying on patient compliance or perception of symptoms. Loop recorder devices can be both implantable (ILR) and external (ELR). Table 1 summarizes the characteristics of the most common diagnostic loop recorders. The retrospective memory differentiates loop recorders from prospective-only event recorders. While event recorders have some usefulness in patients with intermittent palpitations, they have no indication to detect syncope. View this table: Table 1 Most common implantable and external loop recorders Knowledge of what occurs during a spontaneous event is the ideal gold standard for evaluation. Patients with infrequent short-duration transient symptoms, recurring over weeks or months, are unlikely to be diagnosed by conventional Holter monitoring, since the likelihood of symptom-ECG correlation is very low. Consideration should be given to patient-activated event recording in such patients, but this technique has important limitations that might prevent a successful ECG recording of the event, especially for those with syncope, as it implies the activation of recording by the patients once the patient has already recovered consciousness. In such circumstances, consideration should be given to implantable and external ECG loop recorders. It is likely that loop recorders will become increasingly important, and their use will increasingly be appropriate instead of, or before, many current conventional investigations. This early loop recorder approach implies, on the one hand, the need for careful initial risk stratification in order to exclude from such a strategy patients with potential life-threatening conditions that require immediate hospitalization or intensive evaluation and treatment. On the other hand, as a general rule ECG loop recorders are indicated only when there is …

To determine the natural history of late potentials on the signal-averaged electrocardiogram (ECG), multivariate analysis was performed in 167 patients (138 men, 29 women) with a first anterior or inferior acute myocardial infarction. Seventy-four patients received thrombolytic therapy; the remaining 93 patients were treated conventionally. All patients underwent coronary angiography, left ventricular ejection fraction determination and signal-averaged ECG recording. Eight variables thought to be correlated with the presence of late potentials were studied; that is, age, infarct location, number of diseased coronary vessels, left ventricular ejection fraction, infarct-related coronary artery patency, treatment received, delay between admission and signal-averaged recording and delay between admission and coronary angiography. Statistical analysis showed that two independent factors (coronary artery occlusion and impaired left ventricular ejection fraction) were highly correlated with the incidence of late potentials. The occurrence of late potentials was multiplied by 5 in case of an occluded infarct-related vessel and by 1.75 each time the left ventricular ejection fraction value decreased by 0.10. This study suggests that coronary artery patency is the most important factor that decreases the rate of late potentials after a first acute myocardial infarction and it occurs independently of infarct location and left ventricular function.

International audience; OBJECTIVES: This study was designed to compare electroanatomic mapping (EAM) and magnetic resonance imaging (MRI) with delayed contrast enhancement (DCE) data for delineation of post-infarct scars. BACKGROUND: Electroanatomic substrate mapping is an important step in the post-infarct ventricular tachycardia (VT) ablation strategy, but this technique has not yet been compared with a gold-standard noninvasive tool informing on the topography and transmural extent of myocardial scars in humans. METHODS: Ten patients (9 men, age 71 +/- 10 years) admitted for post-infarct VT ablation underwent both a left ventricle DCE MRI and a sinus-rhythm 3-dimensional (3D) (CARTO) EAM (Biosense Webster, Johnson & Johnson, Diamond Bar, California). A 3D color-coded MRI-reconstructed left ventricular endocardial shell was generated to display scar data (intramural location and transmural extent). A matching process allocated any CARTO point to its corresponding position on the MRI map. Electrogram (EGM) characteristics were then evaluated in relation to scar data. RESULTS: A spiky EGM morphology, a reduced unipolar or bipolar EGM voltage amplitude (56 ms) independently correlated with the presence of scar whatever its intramural position. Endocardial scars had a larger degree of signal reduction than intramural or epicardial scars. None of the parameters was correlated with transmural scar depth. A clear mismatch in infarct surface between CARTO and MRI maps was observed in one-third of infarct zones. CONCLUSIONS: Sinus-rhythm EAM helps identify the limits of post-infarct scars. However, the accuracy of EAM for precise scar delineation is limited. This limit might be circumvented using anatomical information provided by 3D MRI data.