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Background: Recurrences of atrial fibrillation (AF) after pulmonary vein isolation (PVI) are mainly due to pulmonary vein reconnection. However, a growing number of patients have AF recurrences despite durable PVI. The optimal ablative strategy for these patients is unknown. We analyzed the impact of current ablation strategies in a large multicenter study. Methods: Patients undergoing a redo ablation for AF and presenting durable PVI were included. The freedom from atrial arrhythmia after pulmonary vein-based, linear-based, electrogram-based, and trigger-based ablation strategies were compared. Results: Between 2010 and 2020, 367 patients (67% men, 63±10 years, 44% paroxysmal) underwent a redo ablation for AF recurrences despite durable PVI at 39 centers. After durable PVI was confirmed, linear-based ablation was performed in 219 (60%) patients, electrogram-based ablation in 168 (45%) patients, trigger-based ablation in 101 (27%) patients, and pulmonary vein-based ablation in 56 (15%) patients. Seven patients (2%) did not undergo any additional ablation during the redo procedure. After 22±19 months of follow-up, 122 (33%) and 159 (43%) patients had a recurrence of atrial arrhythmia at 12 and 24 months, respectively. No significant difference in arrhythmia-free survival was observed between the different ablation strategies. Left atrial dilatation was the only independent factor associated with arrhythmia-free survival (HR, 1.59 [95% CI, 1.13–2.23]; P =0.006). Conclusions: In patients with recurrent AF despite durable PVI, no ablation strategy used alone or in combination during the redo procedure appears to be superior in improving arrhythmia-free survival. Left atrial size is a significant predictor of ablation outcome in this population.

Aims Cardiac resynchronization therapy (CRT) is highly effective in dilated cardiomyopathy (DCM) patients with impaired left ventricular ejection fraction (LVEF) and left bundle block branch. In cardiac amyloidosis (CA) patients, left ventricular dysfunction and conduction defects are common, but the potential of CRT to improve cardiac remodelling and survival in this particular setting remains undefined. We investigated cardiovascular outcomes in CA patients after CRT implantation in terms of CRT echocardiographic response and major cardiovascular events (MACEs). Methods and results Our retrospective study included 47 CA patients implanted with CRT devices from January 2012 to February 2020, in nine French university hospitals (77 ± 6 years old, baseline LVEF 30 ± 8%) compared with propensity‐matched (1:1 for age, LVEF at implantation, and CRT indication) DCM patients with a CRT device. CA patients had lower rates of CRT response (absolute delta LVEF ≥ 10%) compared with DCM patients (36% vs. 70%, P = 0.002). After multivariate Cox analysis, CA was independently associated with MACE (hospitalization for heart failure/cardiovascular death) [hazard ratio (HR) 3.73, 95% confidence interval (CI) 1.85–7.54, P

The mobility of pelvic organs is the result of an equilibrium called Pelvic Static characterizing the balance between the properties and geometries of organs, suspensions and support system. Any imbalance in this complex system can cause of pelvic static disorder. Genital prolapse is a common hypermobility pathology which is complex, multi factorial and its surgical management has high rate of complications. The use of 3 D numerical models and simulation enables the role of the various suspension structures to be objectively studied and quantified. Fascias are connective tissues located between organs. Although their role are described as important in various descriptions of pelvic statics, their influence and role has never been quantitatively objectified. This article presents a refine Finite Element (FE) model for a better understanding of biomechanical contribution of inter-organ fascia. The model is built from MRI images of a young volunteer, the mechanical properties derived from literature data to take into account the age of the patient and new experimental results have enabled an order of magnitude of the mechanical properties of the fascias to be defined. The FE results allows to quantify the biomechanical role of the fascia on pelvic mobility quantified by an analysis of dynamic MRI images and a local mapping of the gap between calculated and measured displacements. This improved numerical model integrating the fascias makes it possible to describe pelvic mobilities with a gap of 1 mm between numerical simulations and measurements, whereas without taking them into account this gap locally reaches 20 mm.

(1) Background: Receiving the first internal electric shock is a turning point for patients with an implantable cardioverter defibrillator (ICD) for primary prevention. However, no study has investigated whether patients who receive a first device-delivered electric shock have a poor prognosis even at the time of ICD implantation. (2) Methods: We retrospectively identified 55 patients with ischemic (n = 31) or dilated (n = 24) cardiomyopathy who underwent ICD implantation for primary prevention with exercise test at the time of implantation. We recorded baseline characteristics, exercise test parameters, and clinical events. (3) Results: After a median follow-up of 5 years, we observed an association between an appropriate device-delivered electric shock, the occurrence of death or heart transplant, and the occurrence of the composite endpoint. There was also a significant relation between a VE/VCO2 slope >35 and the occurrence of the composite endpoint. Conversely, there was no significant association between negative outcomes on the exercise test and the occurrence of a device-delivered electric shock. (4) Conclusions: The exercise test performed at the time of ICD implantation do not predict the occurrence of device-delivered electric shock. The exercise test and the first electric shock are two independent markers of poor prognosis.

Management of left-sided accessory pathways (APs) is based on catheter ablation through an antegrade or retrograde approach. Both are safe and effective but are associated with exposure to x-rays; however, recipients of ablation are generally young. We sought to evaluate the impact of the approach chosen on dose–area product (DAP). A total of 95 patients who underwent radiofrequency ablation of a left-sided AP between January 2011 and January 2020 were included. The primary endpoint was the radiation dose received by the patient. Secondary endpoints were procedural success and complication and recurrence rates. The mean age of the study population was 34.3 ± 16.6 years. The antegrade transseptal approach was used in 63.5% of cases. By multivariate analysis, the antegrade transseptal approach was associated with a 53% reduction in DAP (p < 0.001). The radiation dose received was also significantly associated with body mass index and total fluoroscopy time (p < 0.001). There was no significant difference in other secondary endpoints between approaches. The use of an antegrade transseptal approach is associated with a significant reduction in DAP compared with the retrograde approach, and procedural success and complication and recurrence rates are similar.

International audience; Knitted fabrics are used to manufacture soft implants for medical applications. Once integrated in the body, the fabric forms a new composite material with the native and scar tissues. The mechanical behavior of the composite is assumed to be hyperelastic to match with the physiological behavior of the native tissues and thus to improve the fabric in vivo integration. Being able to predict the mechanical behavior of the composite regarding the tissue nature and the textile properties would accelerate the choice of the appropriate knit. We propose an approach for modeling the mechanical behavior of an hyperelastic material reinforced by a knitted fabric. The main idea of the modeling approach described in the present paper is to couple micro or meso-structural observations with mechanical considerations. Knitted fabric composites display oriented and periodic microstructures. Since most knitted fabrics present a non-linear anisotropic mechanical behavior, the hyperelastic directional formalism seems appropriate to model the reinforced elastomer. This work focuses on the development of a new directional model for the mechanical representation of anisotropic knitted fabric reinforced elastomers. The material is described with the help of a discrete network of directions that contribute distinctively to the material's global behavior. Experimental data obtained on reinforced elastomer composites were used to confirm the accuracy of the results as well as the prediction capabilities of the model. It seems able to represent an anisotropic stress answer of microstructured composite in uniaxial tension.

Cardiologists are among the health professionals that are most exposed to ionizing radiation, but there is no recent study quantifying overexposure of physicians during cardiac resynchronisation therapy (CRT) procedures compared to 'classical' implantation of pacemakers (PMs) or implantable cardioverter-defibrillators (ICDs). We aimed to measure and compare operator exposure to radiation during implantation of PM and ICD with or without CRT. The study population comprised all PMs and ICDs implanted in a large referral centre over a six months period. The endpoint was operator radiation exposure, assessed using a personal electronic dosimeter located on operator's chest. In total, 169 PM/ICD implantations were analysed, 19 of which included CRT. Compared with 'classical' implantation, cardiologist radiation exposure was 9-fold greater during CRT procedures (p < 0.001). Physician exposure was related to dose-area product (R2 = 0.21 during 'classical' implantations and R2 = 0.57 during CRT procedures). Our study shows that cardiologists' exposure to radiation during CRT implantation was 9-fold greater than during procedures without CRT.

Acute myocarditis is associated with cardiac arrhythmia in 25% of cases, a third of these arrhythmias are ventricular tachycardia (VT) or ventricular fibrillation (VF). The implantation of a cardiac defibrillator (ICD) following sustained ventricular arrhythmia remains controversial in these patients. We sought to assess the risk of major arrhythmic ventricular events (MAEs) over time in patients implanted with an ICD following sustained VT/VF in the acute phase of myocarditis compared to those implanted for VT/VF occurring on myocarditis sequelae. Our retrospective observational study included patients implanted with an ICD following VT/VF during acute myocarditis or VT/VF on myocarditis sequelae, from 2007 to 2017, in 15 French university hospitals. Over a median follow-up period of 3 years, MAE occurred in 11 (39%) patients of the acute myocarditis group and 24 (60%) patients of the myocarditis sequelae group. Kaplan&ndash, Meier MAE rate estimates at one and three years of follow-up were 19% and 45% in the acute group, and 43% and 64% in the sequelae group. Patients who experienced sustained ventricular arrhythmias during acute myocarditis had a very high risk of VT/VF recurrence during follow-up. These results show that the risk of MAE recurrence remains high after resolution of the acute episode.

Background Epicardial fat (EF) plays an established role in genesis and persistence of atrial fibrillation (AF) but its impact on endocavitary radiofrequency (RF) ablation remains not considered. This study sought to determine the impact of EF volume on duration of RF during AF ablation procedure. Method EF volume was assessed by computed tomography scans that were systematically performed before ablation. Primary endpoints were total duration of RF and duration of pulmonary vein isolation. Secondary endpoint was the conversion or organization of an arrhythmia after pulmonary vein isolation. The mean follow-up duration was 18 ± 7.3 month. Results A total of 165 subjects, including 72 persistent AF patients, benefit from a first endocavitary RF ablation procedure from March 2015 to July 2017 in Reims university hospital. Persistent AF patients had higher total EF volume than paroxysmal AF patients (72.5 ± 31.7 vs. 55.8 ± 24.5 ml; P = 0.0002). Total duration of RF and duration of pulmonary vein isolation were significantly associated with higher total EF volume (respectively P = 0.007 and P = 0.037) and peri-ventricular EF volume (P = 0.009 and P = 0.029). In multivariate analysis, total EF volume was not significantly associated with total duration of RF (P = 0.46). Regarding individuals with arrhythmia at the time of the procedure, patients whose AF was reduced or organized after pulmonary vein isolation had no less total EF than those whose AF was not (62.6 ± 36.7 vs. 71.3 ± 31.5 ml; P = 0.112) ( Fig. 1 ). Conclusion We highlight a significative association between total, especially peri-ventricular EF volume, and total duration of RF and duration of pulmonary vein isolation. This relation was no more significant in multivariate analysis which gives EF the state of marker of ablation complexity. These results support the causal link between epicardial fat and AF and emphasize the importance of peri-ventricular EF role.

Patients who underwent radiofrequency ablation of atrial fibrillation are exposed to X-rays not only during the procedure but also during the preprocedural computed tomography. No study has investigated the cumulative effective dose received by patients who underwent atrial fibrillation ablation and identified factors influencing this dose. We aimed to evaluate the overall exposure to ionizing radiation in patients who underwent radiofrequency ablation of atrial fibrillation. The secondary objective was to estimate the impact of obesity on this exposure. All patients who underwent a first attempt of radiofrequency ablation of atrial fibrillation in our center over a 21 months period were included. Dosimetric indicators from preprocedural computed tomography and the ablation procedure were collected and converted into an effective dose. A total of 144 radiofrequency ablation of atrial fibrillation were included. The mean cumulative effective dose was 11.4 mSv, and 82% of the dose was from the computed tomography. Obese patients received a dose that was 75% higher than normal-weight patients, and this increase remained significant by multivariate analysis. In conclusion, overall exposure to ionizing radiation for patients who underwent radiofrequency ablation of atrial fibrillation seems acceptable, and the majority of the overall effective dose comes from the computed tomography. Obese patients are exposed to a 75% higher dose than normal-weight patients.

Cardiologists are among the health professionals that are most exposed to ionizing radiation, but there is no study comparing the level of exposure of physicians during different electrophysiology procedures. We aimed to measure and compare cardiologists’ exposure to radiation during different electrophysiology procedures. The study population comprised all electrophysiology procedures performed over a 6-month period in a large referral centre. The endpoint was operator radiation exposure, assessed using a personal electronic dosimeter located on the operator’s left arm. In total, 150 electrophysiology procedures were analyzed. Compared with electrophysiology studies (reference category), physician radiation exposure was 3-fold greater during ablation of atrial fibrillation, 9-fold greater during ablation of atrioventricular nodal reentrant tachycardia (AVNRT)/atrioventricular reentrant tachycardia (AVNT), and 10-fold greater during ablation of atrial flutter (p

We assessed Enterovirus (EV) &Parvovirus B19 (PVB19) genomes and CD3, CD68&HLA-DR detection in dilated cardiomyopathies (DCM). EV&PVB19 genomes and CD3, CD68&HLA-DR were detected by PCR and immunohistochemistry assays in 115 endomyocardial biopsies obtained in 13 idiopathic DCM (iDCM) and 10 explained DCM (eDCM) patients. Results were compared with those of 47 atrial surgical samples (47 surgery controls) and 22 autoptic cardiac samples (11 healthy heart controls) (2008-2014, Reims, France). EV was detected in 23.1% of iDCM patients but not in eDCM and controls (P = 0.003) (viral load 803 copies/μg). PVB19 was detected in 76.9%, 80.0%, 63.6% and 78.2% of iDCM, eDCM, healthy heart and surgery controls (P = 0.99) with a mean viral load of 413, 346, 1,428, and 71 copies/μg. CD3, CD68 or HLA-DR were detected in 100 and 50% of EV and PVB19 "mono-infected" iDCM patients. EV was exclusively detected in iDCM cases in association with CD3, CD68, or HLA-DR indicating that EV could be an etiological cause in a subset of iDCM cases. By contrast the equal frequent detection of PVB19 in iDCM cases and controls without association with CD3, CD68, or HLA-DR suggested that PVB19 could be a bystander in many DCM cases. J. Med. Virol. 89:55-63, 2017. © 2016 Wiley Periodicals, Inc.

Aims This study aimed to determine the impact of the volume of epicardial fat on the duration of radiofrequency (RF) energy delivery during the procedure of ablation of atrial fibrillation (AF). Methods The volume of epicardial fat was measured from spiral computerized tomography scan. The primary endpoint was the duration of RF delivery for pulmonary vein isolation (PVI), and the overall total duration of RF application. Secondary endpoint was conversion of AF to sinus rhythm or organisation of the arrhythmia after PVI. Results From March 2015 to May 2018, 222 patients (45.5% with persistent AF) underwent a first RF catheter ablation procedure for AF. The total duration of RF delivery, and the duration of RF delivery specifically for PVI were significantly associated with higher total volume of epicardial fat (p = 0.0002; p = 0.009 respectively), periatrial (p = 0.003; p = 0.045) and periventricular epicardial fat (p = 0.001; p = 0.012). In multivariate analysis, total epicardial fat volume was not significantly associated with total RF delivery duration (p = 0.743). For patients with arrhythmia at the time of the procedure, patients who achieved conversion or organisation of their arrhythmia after PVI had similar levels of total epicardial fat to those whose arrhythmia persisted (65 ± 35.2 vs 74.5 ± 31.2 ml; p = 0.192). Conclusion We observed a significant relation between total, periatrial, and periventricular epicardial fat, and the duration of RF delivery during ablation of AF. This relation was not significant by multivariate analysis meaning that epicardial fat may be a marker, but not an independent factor, of ablation complexity.

Introduction Many studies have shown a high prevalence of sleep apnea syndrome (SAS), whether obstructive sleep apnea (OSA) or central sleep apnea (CSA) in heart failure patients (HF). Very few data exit about HF patients with cardiac resynchronization therapy (CRT). Purpose In this study, we will determine the prevalence of SAS in this population and study the influence of CRT about SAS. Methods A prospective open-label, single-center, non-interventional, cohort-type study was conducted at Reims University Hospital between 1st January and 31st August 2016. All patients implanted with CRT device without known SAS were included. Screening polysomnography was performed before and 6 months after implantation. Primary endpoint was the incidence of SAS and secondary endpoint was the evaluation of the impact of CRT on SAS. Results During the study period, 31 patients were implanted with a CRT device: 10 were already known having SAS and 5 did not give their consent. At M0, 100% of the 16 included patients were diagnosed having SAS, with 69% severe OSAS. All were treated by CPAP according to guidelines. At 6 months, after 48 h CPAP washout, no independent significant influence of CRT on the Apnea-Hypopnea Index (AHI) was demonstrated (37 ± 19 vs 60 ± 12, P = 0.0625). An improvement in HF parameters was observed (NYHA class (−1, P = 0.0195), QRS width (−26 ms, P = 0.0002) and LVEF (+9.5%, P = 0.0039)). At 6 months, the CRT response rate was high with significant NYHA class and LVEF improvement in 79 and 57% patients respectively. Conclusion SAS (especially OSA) is frequent in HF patients eligible for CRT and mostly under-diagnosed. The lack of improvement of the AHI by the CRT alone and the existence of a specific treatment of the OSAS improving morbi-mortality, maintaining a very good response rate to the CRT invite to screen this population.

To better understand the in vivo mechanical behavior of synthetic mesh implants, we designed a specific experimental protocol for the mechanical characterization of explanted mesh under uniaxial tension. The implantation of a mesh leads to the development of scar tissue and the formation of a new composite made of native tissue, a mesh implant and scar tissues. This study focused on three points: determining the minimum representative size of mesh implants required for mechanical test samples, highlighting the influence of healing, and defining the healing time required to ensure stabilized mechanical properties. First, we determined the minimum representative size of mesh implants for the mechanical characterization with a study on a synthetic composite made of mesh and an elastomeric matrix mimicking the biological tissues. The size of the samples tested was gradually decreased. The downsizing process was stopped, when the mechanical properties of the composite were not preserved under uniaxial tension. It led to a sample representative size 3cm long and 2cm wide between the grips. Then an animal study was conducted on Wistar rats divided into eight groups. One group was set as control, consisting of the healthy abdominal wall. The other seven groups underwent surgery as follows: one placebo (i.e., without mesh placement), and six with a mesh installation on the abdominal wall and healing time. The rats were sacrificed after different healing times ranging from 1 to 5 months. We observed the influence of healing and healing time on the mechanical response under uniaxial tension of the new composite formed by scar, native tissue, and textile. It seems that 2 months are required to ensure the stabilization of the mechanical properties of the implanted mesh. We were not able to tell the control group (native abdominal wall) from the placebo group (native and scar tissue). This protocol was tested on two different prostheses after 3 months of healing. With this protocol, we were able to differentiate one mesh from another after host integration.

Due to their high deformability, the elastomers are widely used in various fields of applications. Their hyper-elastic behavior requires means of characterization adapted to contactless, high strain as well as heterogeneous strain field. Digital Image Correlation (DIC) have been used to characterize such material. In case of large strain it might be necessary to re-actualize the reference image to compute the displacement field on every images of the test. Different strategy to apply DIC in large strain are presented. The direct addition of the successive calculated displacement leads to inconsistent results, it is required to make a composition of the successive calculated displacements. Some artefacts due to the multiple interpolation are highlighted and may leads to filter the results. In case of high strain gradients, a method with very small element size and median filter applied directly in correlation process has been used highlighting the ability of large strain DIC in heterogeneous media.

Background Cardiologists are increasingly encountering oldest-old patients with rhythm disturbances requiring implantation of a pacemaker, but few data exist regarding patients aged 90 years and over. Aim To analyse procedural complications, evaluate the long-term survival of nonagenarians after a first implantation of a pacemaker, and identify predictors of mortality in this population. Methods Retrospective study of 1326 patients aged 90 years and over from two centres who underwent first implantation of a pacemaker between June 2010 and February 2015. The primary endpoint was all-cause mortality. Secondary endpoints were immediate and long-term complications after implantation. Results A total of 104 patients, average aged 92.7 ± 2.8 years, were included; 63.8% had a single-chamber and 36.2% had a dual-chamber pacemaker implanted. Median survival was 31 months (2.6 years, 95% confidence interval (CI) 21.7–40.3). Two-year survival was 61.9%. Overall, 3.8% of patients had complications, including 0.95% serious complications related to the procedure. Age > 92 years at the time of implantation, body mass index (BMI) Conclusion First-time implantation of a pacemaker is safe in patients aged 90 years and over. Complications and mortality up to 2 years after implantation are not related to the pacemaker. Charlson comorbidity index and BMI are independently related to survival.

Dear Editor,We read with interest a recent review article in the present journal in which evidence in favour of Borrelia burgdorferi as an aetiological agent of vasculitis and stroke was presented....

We assessed Enterovirus (EV)Parvovirus B19 (PVB19) genomes and CD3, CD68HLA-DR detection in dilated cardiomyopathies (DCM). EVPVB19 genomes and CD3, CD68HLA-DR were detected by PCR and immunohistochemistry assays in 115 endomyocardial biopsies obtained in 13 idiopathic DCM (iDCM) and 10 explained DCM (eDCM) patients. Results were compared with those of 47 atrial surgical samples (47 surgery controls) and 22 autoptic cardiac samples (11 healthy heart controls) (2008-2014, Reims, France). EV was detected in 23.1% of iDCM patients but not in eDCM and controls (P = 0.003) (viral load 803 copies/μg). PVB19 was detected in 76.9%, 80.0%, 63.6% and 78.2% of iDCM, eDCM, healthy heart and surgery controls (P = 0.99) with a mean viral load of 413, 346, 1,428, and 71 copies/μg. CD3, CD68 or HLA-DR were detected in 100 and 50% of EV and PVB19 "mono-infected" iDCM patients. EV was exclusively detected in iDCM cases in association with CD3, CD68, or HLA-DR indicating that EV could be an etiological cause in a subset of iDCM cases. By contrast the equal frequent detection of PVB19 in iDCM cases and controls without association with CD3, CD68, or HLA-DR suggested that PVB19 could be a bystander in many DCM cases. J. Med. Virol. 89:55-63, 2017. © 2016 Wiley Periodicals, Inc.

The increased use of implantable cardiac devices has been accompanied by an increase in infection. However, risk factors for infection of implanted devices are poorly documented. We aimed to identify risk factors in patients with long-term follow-up after implantation of cardiac devices.Patients with first implantation of a cardiac device in our centre between October 1996 and July 2007 were entered in a registry. Each confirmed infection of the implanted device was matched to two controls for age, sex, and implantation year. We recorded cardiovascular risk factors (hypertension, diabetes), previous history of heart disease, renal failure, antiplatelet or anticoagulant therapy, as well as pre- and post-procedural characteristics (antibiotic prophylaxis, hyperthermia, number of leads, associated interventions, and early complications). During the study period, 2496 patients underwent implantation of a cardiac device; 35 infections were diagnosed (1.2%). Among these, 75% occurred during the first year after implantation. Early non-infectious complication requiring surgical intervention was observed only in patients with infection (9 of 35, P0.001). Factors independently associated with infection were diabetes [odds ratio (OR) 3.5, 95% confidence interval (CI) [1.03, 12.97]], underlying heart disease (OR 3.12, 95% CI [1.13; 8.69]), and use of1 lead (OR 4.07, 95% CI [1.23, 13.47]). These latter two risk factors were also independently associated with occurrence of infection within 1 year of implantation.Our data show that the presence of diabetes and underlying heart disease are independent risk factors for infection after cardiac device implantation. As regards procedural characteristics, the use of several leads and early re-intervention are associated with a higher infection rate.

Background Human Herpesvirus 6 (HHV-6) is an important cause of fulminant or acute viral myocarditis in immunocompromised or immunocompetent patients. However the physiopathological mechanisms of HHV-6 related acute myocarditis and the involvement of subsequent HHV-6 reactivation phases in the development of chronic cardiomyopathies remain to be assessed. Objectives To describe a case of fatal HHV-6 chronic myocarditis in an immunocompetent adult. Study design Case report and detailed histological and viral diagnoses by combination of histology/immunohistochemistry and polymerase chain reaction techniques on cardiac tissues. Results Histopathological analysis of ventricular tissues showed large interstitial and scarring fibrotic areas with a moderate mononuclear cell infiltrate compatible with histological aspect of chronic myocarditis. Detection of both HHV-6 by real-time PCR and viral glycoproteins in mononuclear and endothelial cells by immunohistochemistry evidenced an ongoing cardiac HHV-6 replication with viral late protein synthesis activity. Conclusions This case report indicates that HHV-6 can establish a chronic active myocarditis leading to heart failure in immunocompetent subjects.

International audience

Background Approximately 1% of the adult population have heart failure with reduced ejection fraction. Since the 1980s, therapeutic advances in this field have been significant, particularly through the development of cardiac resynchronization therapy (CRT). However, transvenous implantation of the left ventricular (LV) lead is unsuccessful in 5 - 15% of patients. For this group, surgical placement of LV lead is an alternative. Objective Compare the effects of transvenous versus surgical implantation of the LV lead in CRT. Methods We included 100 consecutive patients who had received CRT in our centre between January 2008 and July 2012 in a retrospective observational study. Twelve patients who had failed transvenous implantation of LV lead had a surgical placement. Results Population characteristics were a mean age of 66±11 years, 16% female, New York Heart Association class 2.9±0.5, 45% ischemic cardiomyopathy, left ventricular ejection fraction (LVEF) 24±7%, QRS width 165±23ms. There were no major difference in preoperative variables between two groups except sex category (12.5% female in transvenous group versus 42% in surgical group, p=0.022). During a mean follow-up of 508±429 days, the improvements seen in all variables showed no difference between the groups. At six months, 77% of patients had improved at least one class of their dyspnea stage, LVEF improved significantly (24±7% versus 36±10% at six months). Conclusions Surgical placement of LV lead offers similar benefits as compared with transvenous implantation.

Background Radiofrequency ablation (RFA) is the only curative treatment for typical atrial flutter (AFL) and allows stopping antiarrhythmic drugs. However, atrial fibrillation (AF) is frequent during follow-up but predictive factors of AF onset are unknown while it is necessary to diagnose it in order to apply the correct antithrombotic strategy. Aims To determine prevalence and predictors of AF after AFL RFAAFL. Methods From January 2012 to December 2013, patients who underwent RFA of cavotricuspid isthmus for typical atrial flutter in our centre were retrospectively included. Results Of 166 patients (137 men, mean age: 66.7±10 years), 61 (36.7%) had a history of AF. The mean CHA2DS2VASc and HASBLED scores were 2.49 and 1.11. Mean left ventricular ejection fraction was 53±13% and 77 (46.4%) patients had a subsequent cardiomyopathy, whereas 61 (36.7%) had a history of AF. Of 166 RFA, sinus rhythm was obtain in 160 patients and 141 (84.9%) procedures were considered as a complete success (complete isthmus block). During a mean follow up of 489±244 days, there were 7 (5%) and 9 (36%) AFL recurrence in patients with and without isthmus block respectively. New-onset or recurrent AF were experienced by 63 (39%) patients. History of AF was an independent predictive factor of AF (33 (52.4%) vs. 28 (27.2%) patients; p=0.002). The younger patients (64.4 ±11.7 vs. 68.2±9.9 years; p=0.03) and patients with lower CHA2DS2VASc score had more AF post ablation (2.16±1.53 vs. 2.70±1.57; p=0.03). Conclusion After successful RF ablation, AF was frequent in patients especially in patient with AF history before AFL RFA, but also occurred in patient with lone AFL. Age and CHA2DS2VASc score were inversely associated with onset of AF. Identify AF and risk patients is crucial regarding to long-term antithrombotic therapy. Abstract 0362 – Table: predictive factors of AF No FA post ablation(N=103) FA post ablation (N=63) p Men/Women (N/N) 89/14 48/15 0.09 Age (years) 68.2+/–9.9 64.4+/–11.7 0.03* SAS 10 (9.7) 4 (6.3) 0.57 Cardiopathy 53 (51.5) 24 (38.1) 0.11 History of AF (N [%]) 28 (27.2) 33 (52.4) 0.002* Dilated LA (N [%]) 43 (41.7) 32 (50.8) 0.4 Dilated LV (N [%]) 12 (11.7) 12 (19) 0.41 LVEF 29 (28.2) 10 (15.9) 0.09 High blood pressure (N [%]) 63 (61.2) 31 (49.2) 0.14 Age ≥75 years 29 (28.2) 15 (23.8) 0.59 Diabetes mellitus 18 (17.5) 9 (14.3) 0.66 CHA 2 DS 2 VASc 2.7+/–1.57 2.16+/–1.53 0.03* BMI (kg/m 2 ) 27.4+/–5.5 27.9+/–4.9 0.55 Creatinine clearance (Cockroft) 78.1+/–30.8 85.3+/–37.4 0.19 Creatinine clearance (MDRD) 72.8+/–22.4 73.9+/–23.7 0.76 SAS: sleep apnoea syndrome; AF: atrial fibrillation; LA: left atrial; LV: left ventricular LVEF: left ventricular ejection fraction; BMI: body mass index

Background Congenital heart disease (CHD) are seldom cured and the increasing grown-up congenital heart disease (GUCH) population still needs specialized follow-up that has to be organized. In Reims University Hospital, it's about 10 years ago that pediatric and adult cardiologists initiated a multidisciplinary clinic for follow-up of GUCH patients. Objectives The aim of the present study is to describe the GUCH population followed in our hospital (CHD, treatments, outcomes, complications, social issues) and the organization of their medical care. Methods This is a retrospective and observational study including patients with CHD which were over 18 years old in September 2013 and were seen in Reims University Hospital at least once between January 2008 and September 2013. Results Our GUCH population was 475 patients. Median age was 25.1 years old. Sex ratio was 0.82. Among CHD, univentricular hearts were 10%. Thirty-one percent of patients were taking cardiologic medications. Cardiac surgery had been performed in 62.1%. Interventional catheterization had been undertaken in 19.6%. Regarding the outcome, main complications were arrhythmias (17%), heart failure (5%), pulmonary hypertension (4%), endocarditis (1.2%), death (1.9%). Social supervision was needed in 14.3%. Twenty-six percent of patients had a life partner and 12.4% had children. During the period study, 11.7% of patients were lost to follow-up. Conclusions After reaching adulthood, patients with CHD need continuous follow-up because complications in GUCH patients are not uncommon. Although transition between adolescence and adulthood is supposed to be at high risk of breaking this follow-up, the present study shows that it is possible to minimize this event. We feel that an organized continuum of care between pediatric and adults cardiologists, as we settled in our hospital, could be an effective way to meet the special needs of GUCH patients.

Summary Introduction The Brugada syndrome is a rare genetic disease that can lead to death. Its diagnosis requires electrocardiography. Case A 36-year-old man was admitted with syncope. Brugada syndrome was diagnosed by the typical ECG pattern. The interaction between lithium therapy and ECG was shown clearly by the alternating type 1 and type 3 Brugada ECG patterns, depending on lithium status. Discussion The Brugada syndrome may be unmasked by lithium therapy, due to its properties as a Na+ channel blocker, even at low doses. This case also demonstrated the usefulness of ECG in detecting the Brugada syndrome before and during lithium prescription.

BackgroundConsidering morbidity and financial impact on the health care system, it may be helpful to stratify patients who would most benefit from primary ICD treatment. The aim of this study was to assess the prevalence and identify the clinical predictors of appropriate ICD therapy in patients following implantation of an ICD in primary prevention for chronic heart failure.MethodsA monocenter retrospective analysis was performed and all patients undergoing implantation of ICD in primary prevention were included. Device interrogations were performed and appropriate therapies, either ATP or shock, were noticed.ResultsOver the 317 primary prevention patients undergoing ICD implantation, 203 had ischemic cardiomyopathy (ICM) and 114 had nonischemic dilated cardiomyopathy (NIDCM). At the median follow-up time 760±599 days, 56 (17,7%) had received appropriate ICD therapies. Average Figure: Predictors of appropriate ICD therapyLVEF was 26±6%. By univariate comparison, LVDD≥65mm (p=0,035) and lack of diuretic (p=0,024) were significant predictors for ICD therapy. ICM and NIDCM patients benefit equivalently from ICD implantation (p=0,941). By multivariate analysis, elderly patients ≥65y (HR 1,92, p=0,032), LVDD≥65mm (HR 2,01, p=0,022) and lack of diuretic (HR 0,31, p

Introduction Age is a major thrombo-embolic risk factor in atrial fibrillation (AF), but also a risk factor for bleeding under oral anticoagulation therapy (OAC). However, it appears that older patients are inadequately treated with OAC. The objective of our study was to evaluate the use of OAC in elderly patients hospitalised in a cardiology department according to current guidelines. Method Over a 4-month period, 142 patients over 75 years old with history of AF were included. Clinical and biological data were recorded, and risk scores for bleeding (HASBLED) and thrombo-embolic events (CHADS2 and CHA2DS2VASc) were independently assessed after discharge. The differences between bleeding and thrombo-embolic risk were calculated for each patient. Patients with OAC at discharge and patients without OAC were compared. Results Mean age was 83±13 years (75 men). Mean CHADS, CHADSVASc and HASBLED scores were respectively 2,6±0,1, 4,6±0,1 and 2,3±0,1. According to CHADSVASc score and guidelines all of the patients were eligible for OAC. However 47.8% of patients were not under OAC. Those patients were older (84.6±0.6 vs. 81.8±0.5; p=0.001), predominantly female (66 vs. 35%; p=0.001) with a higher serum creatinine (127.3±7.3 vs. 106±6.3; p=0.03) and HASBLED score (2.7 vs. 2.16; p=0.001). OAC use was not associated with CHADS and CHADSVASc scores values. OAC No OAC T (CHADS) >B 49.2% 39% * T (CHADS) 2.3% μ 9.2% T (CHADSVASC) >B 47% 40% * T (CHADSVASC) 3.8% μ 8.4% T Thrombo-embolic risk; B: bleeding risk (HASBLED) according to scores * undertreated patients according to scores μ over-treated patients according to scores Conclusion Our study in daily pratice confirms that OAC in older patients with AF are underused and that the bleeding risk may be over-rated and/or thrombo-embolic risk under-estimated. However, specific risk factors in older patients may not be included in currently used scores.

Introduction Studies have documented the underuse of oral anticoagulant therapy (OAC) as stroke prophylaxis in older persons with history of atrial fibrillation (AF). Failure to prescribe OAC is often due to the perception by physicians of bleeding because of specific older people clinical factors. We performed a prospective observational study in the University Hospital of Reims, whose aim was to evaluate the management of thromboembolic risk in older patients in everyday-life hospital practice and impact of frailty and dependence objective parameters. Method 150 AF patients over 75 years were consecutively included over a period of four months. Clinical and biological data, risk scores for bleeding (HASBLED) and thrombo-embolic events (CHADS and CHADSVASc) were computed. Several scores and parameters of assessment of autonomy and risk of falling were independently recorded: MMS (Mini-Mental Status), ADL (Activities of Daily Living) and IADL (Instrumental ADL). Results Mean age was 83±13 years (75 men). At discharge, 52.2% of patients were under OAC. Mean CHADS, CHADSVASc and HASBLED score were respectively 2,6±0,1, 4,6±0,1 and 2,3±0,1; all patients had a CHA DS VASc score ≥2 and 86% a CHADS ≥2. The HASBLED score was associated with non-prescription of anticoagulation (p=0.001), while none of the thrombo-embolic scores was significantly associated with prescription. Specific studied parameters are in table. Anticoagulation N=74 No anticoagulation N=68 p Age (years) 81.8±0.5 84.6±0.6 0.001 Creatinine (μmol/l) 106±7.3 127.3±6.3 0.03 Dependency (%) 27 54 0.001 Dementia (%) 4,1 14,7 0.04 High risk of falling (%) 0 20 0,001 MMS score 21.4±1.2 20.1±1.1 NS ADL score 5.1±0.3 3.8±0.4 0.001 IADL score 2±0.2 2.4±0.4 NS Conclusion In our study of everyday practice, there is an underuse of anticoagulation in the elderly compared to guidelines, mainly because the perception of the hemorrhagic risk prevails over the thrombo-embolic risk. Specific geriatric parameters could help to choose the appropriate therapy.

Standardized one-step real-time RT-PCR assay detected enterovirus RNA in cardiac biopsy samples from 4 of 20 patients suffering from idiopathic dilated cardiomyopathy (IDCM). The median viral load was 287 copies per microgram of total extracted nucleic acids, with positive- to negative-strand RNA ratios ranging from 2 to 20. These results demonstrate enterovirus persistence in the heart of IDCM patients, characterized by low viral loads and low positive- to negative-RNA ratios.

Summary Background Cardiovascular disease is the primary cause of mortality and morbidity among patients with chronic kidney disease. Aims To investigate whether echocardiography can predict the occurrence of major cardiovascular events in patients with severe chronic kidney disease. Patients Patients with stable stage 4 chronic kidney disease (estimated glomerular filtration rate 15–29 mL/min/1.73 m2) and followed in the nephrology department were included. Clinical, biological, electrocardiographic and echocardiographic data were recorded. Endpoint was defined as fatal or non-fatal cardiovascular event (acute coronary syndrome, acute heart failure, stroke, sustained ventricular arrhythmias, arterial thrombotic events and death). Results We included 71 patients (46 men); mean age 72 ± 14 years. Mean glomerular filtration rate was 21.9 ± 4.8 mL/min/1.73 m2. Over a mean follow-up of 258 ± 30 days, 18 (25%) patients reached endpoint (death in 7/18). Male sex, blood urea, atrial fibrillation, Sokolow index, left atrial size, pulmonary arterial pressure, indexed left ventricular mass and protodiastolic peak velocity of transmitral Doppler flow were significantly higher whereas left ventricular ejection fraction was significantly lower in these patients. By multivariable analysis, blood urea and left ventricular ejection fraction remained predictive of major cardiovascular event with odds ratios of 1.10 (95% confidence interval 1.02–1.18) and 0.93 (95% confidence interval 0.89–0.97), respectively. The negative predictive value was 95% when left ventricular ejection fraction was > 50% with blood urea Conclusion Patients with stage 4 chronic kidney disease are at high risk of major cardiovascular events and death. Echocardiographic evaluation is effective in identifying patients at highest risk of adverse cardiac events.

Background Radiofrequency ablation (RFA) is the only curative treatment for typical atrial flutter (AFL) and allows stopping antiarrhythmic drugs. However, management of long-term anticoagulant therapy (LT ACT) remains unclear, especially in lone AFL successfully treated and CHA 2 DS 2 VASc score ≥1. Abstract 0163 – Table: Table Long-term anticoagulation therapy management A GROUP (N=74) B GROUP (N=63) C GROUP (N=17) AF YES (N [%]) NO (N [%]) YES (N[%]) NO (N [%]) YES (N [%]) NO (N [%]) TAC YES (N [%]) 14 (18.9) 11 (14.9) 29 (46) 20 (31.7) 4 (23.5) 0 (0) NO (N [%]) 2 (2.7) 43 (58.1) 3 (4.8) 7 (11.1) 6 (35.3) 5 (29.4) LTFUP (N [%]) 4 (5.4) 4 (6.4) 2 (11.8) AF: Atrial fibrillation ACT: anticoagulant therapy LTFUP: lost to follow up patient Aims Assessment of long-term ACT after AFL RFA according to associated atrial fibrillation (AF) and CHA 2 DS 2 VASc score. Methods From January 2012 to December 2013, patients who underwent RFA of cavotricuspid isthmus for typical atrial flutter in our centre were retrospectively included. Results Of 166 patients (137 men, mean age: 66.7±10years), 61 (36.7%) had a history of AF. The mean CHA 2 DS 2 VASc score was 2.49. The patients were classified according to theoretical indication of LT ACT (patients with a non rhythmic ACT indication excluded – N=12; 7.2%): group A (LT ACT unclear) included patients with CHA 2 DS 2 VASc score ≥1, successful RF ablation and without AF history (N=74); group B (LT ACT indicated) included patients with CHA 2 DS 2 VASc score ≥1, AF history and/or failed AFL RFA (N=63); group C (LT ACT not indicated)included patient with CHA 2 DS 2 VASc score=0 (N=17). During a mean follow up of 489±244 days, 45 (60.8), 10 (15.9%) and 11(64.7) patients stopped ACT respectively in group A, B and C differently according to AF onset (table). There were 8 (4.8%) hemorrhagic and 2 (1.2%) ischemic complications, all in patients with correct ACT management. The prevalence of AF during follow-up was 38%. Conclusion After successful AFL RF ablation, ACT was frequently stopped in the absence of associated AF. However, AF was frequent even inpatients with no AF history. Ischemic and hemorrhagic complications were rare. ACT should be regularly evaluated during follow-up especially according to CHA 2 DS 2 VASc score and new onset of AF.

Implantable cardioverter defibrillator (ICD) has been shown to be associated with a significant reduction in the risk of sudden cardiac death. The aim of this study was to assess the prevalence and to identify the clinical predictors of appropriate ICD therapy in patients with chronic heart failure following implantation of an ICD for primary prevention. A monocenter retrospective analysis was performed and all consecutive patients undergoing implantation of ICD for primary prevention were included. Device interrogations were performed and appropriate therapies were recorded. The endpoint follow-up was the last available device interrogation in our center. Of 317 primary prevention patients undergoing ICD implantation, 203 (64%) had ischemic cardiomyopathy (ICM) and 114 had non-ischemic dilated cardiomyopathy (NIDCM). After a mean follow-up time 760±599 days, 56 (17.7%) had received appropriate ICD therapies. Mean LVEF was 26±6%. By univariate comparison, LVDD≥65mm(p=0.035) and lack of diuretic (p=0.024) were predictors for ICD therapy. Absence of cardiac resynchronization therapy device (CRTD) was close to be significant (p=0.055). ICM and NIDCM patients benefit from ICD implantation did not differ (p=0.941). By multivariate analysis, elderly patients≥65y (HR 1.92, p=0.032), LVDD≥65mm(HR 2.01, p=0.022) and lack of diuretic (HR 0.31, p