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Background Premature ventricular contractions (PVCs) are common in routine medical practice. PVCs are commonly asymptomatic but can also result in palpitations, dyspnea, presyncope or PVC-induced cardiomyopathy that may lead to sudden death. Cardiovascular magnetic resonance (CMR) provides morphological, functional, and tissue characterization in a single setting. CMR imaging proved to reliably identify fibrotic lesions and, hence, has developed into a valuable tool for etiological orientation in patients with PVCs. Objectives The aims of this study were: 1) to evaluate which ventricular arrythmia (VA) characteristics predicted CMR abnormalities and 2) the diagnostic yield and the impact in the management of CMR-based imaging versus non-CMR-based imaging in patients referred for PVCs. Methods This monocentric retrospective study was conducted in patients with PVCs referred for CMR imaging. Their baseline interview and characteristics, physical examination, surface electrocardiogram (ECG) analysis, ambulatory monitoring, echocardiography and treadmill exercise test data were collected when they were available. The CMR (1,5 T and 3.0 T) protocol included cine imaging and late gadolinium enhancement (LGE) using standard cardiac geometries. Results We analyzed 168 patients (65% males, mean age 54.2±16.8 years) referred to our center for PVCs over a two-year period. CMR reported abnormal findings in 73 patients (43.5%) with the diagnosis of structural heart disease (SHD) in 46 patients (27.4%). Left-ventricular late gadolinium-enhancement was documented in 43 patients with abnormal CMR. Using a multivariate analysis, age (p=0.026), sustained ventricular tachycardia (p=0.002) and presence of cardiomyopathy on echocardiography (p Conclusions Age, sustained ventricular tachycardia and presence of cardiomyopathy on echocardiography were the strongest predictors of positive CMR imaging results. Although echocardiography is generally used in first intention for the diagnosis of cardiomyopathy in patients with PVCs, this study showed that CMR-based imaging has a robust diagnostic yield in this indication. Funding Acknowledgement Type of funding sources: None.

Background Mutations in SCN5A are identified in approximately 20% to 30% of probands affected by Brugada syndrome (BrS). However, in familial studies, the relationship between SCN5A mutations and BrS remains poorly understood. The aim of this study was to investigate the association of SCN5A mutations and BrS in a group of large genotyped families. Methods Families were included if at least 3 family members were carriers of the SCN5A mutation, which was identified in the proband. Families were recruited from 12 tertiary centers in France between 1995 and 2020. Type 1 ST elevation was defined by ≥2 mm J-point elevation with coved ST segment and negative T wave. Results Forty-nine large families composed of 600 members including 304 mutation carriers (51%) were studied. The signature type I ECG was present in 160 mutation carriers (BrS-ECG+; 53%). In 42 families, we found 33 individuals affected by BrS but with a negative genotype (mutation-negative BrS-ECG+). Among them, 5 patients have an ECG suggestive of BrS but without the complete signature type I ECG. Among these 33 mutation-negative BrS-ECG+ individuals, 3 (9%), belonging to 3 different families, had a spontaneous type I ECG, whereas 28 had a type I ECG only after the administration of sodium channel blockers. Three of these 33 individuals (9%) had also experienced syncope. Mutation carriers had, on average, longer PR (190±36 ms vs 154±29 ms, p Conclusions Our results suggest that SCN5A mutations are not directly causal to the occurrence of a BrS-ECG+ and that genetic background may play a powerful role in the pathophysiology of BrS. These findings are consistent with the notion that the pathophysiology of BrS includes various elements beyond mutant sodium channels. Funding Acknowledgement Type of funding sources: None.

Background We have recently demonstrated association of unexplained sudden cardiac arrest (SCA) with inheritance of catecholamine induced QT prolongation (CIQTP). Objective We here aim to describe incidence, characteristics and prognosis of this new syndrome in young patients with unexplained SCA or their relatives. Methods We reviewed the medical screening of all consecutive patients or their first-degree relatives explore from 2015 after the occurrence of a SCA before age 45. Structural heart disease or inherited arrhythmia diseases were excluded. A mental stress test was performed, as previously described, for each family members. All families with a positive mental stress were included in the study. Genetic screening was performed in at least one positive patient per family using targeted sequencing on a panel of 109 genes associated with inherited arrhythmias and cardiomyopathies. Results Among 456 patients screened (24 after SCA, 432 for familial screening) of 153 families, we identified 10 families (6.5%) with a catecholamine induced QT prolongation. No mutation was identified in these families. One hundred and ten patients were screened in CIQTP families. Thirty-four patients (30.9%) presented a CIQTP (mean age 42±20 yo, 64.7% of women). Five (14.7%) patients presented with previous symptoms (including 4 syncope and 1 SCA). Two patients (5.9%) were implanted with an ICD and eleven (32.3%) were treated with beta blocker therapy mainly because of QT prolongation >500 ms after mental stress test or previous symptoms. After a 3.6±1.8 years of follow up, no sudden cardiac death nor syncope occurred on beta blocker therapy except for one patient implanted with an ICD after a SCA. Under beta blocker treatment the patient was asymptomatic for 5 years. After a suddenly stop of the beta blocker treatment, the patient underwent VF. For 3 years now the patient is asymptomatic under beta blocker treatment. Conclusions In our experience, CIQTP families represent 6.5% of cases of unexplained SCD and suggest systematic screening with a mental stress test for family screening after the occurrence of a SCA. Beta blocker therapy is very efficient to reduce the risk of SCA. Funding Acknowledgement Type of funding sources: None.

Background Heart failure (HF) is a chronic disease affecting 64 million people worldwide and places a severe burden on society because of its mortality, numerous re-hospitalizations and associated costs [1–4]. HeartLogic is an algorithm incorporating several biometric parameters which aims to predict HF episodes. It provides an index which can be monitored remotely, allowing preemptive treatment of congestion to prevent acute decompensation [5–7]. Objectives We aim to provide real-world data on the impact of pre-emptive HF management, guided by the HeartLogic index on unscheduled HF hospitalizations in a substantial cohort of patients. Methods The HeartLogic French Study is an investigator-initiated, prospective, multi-centre, non-randomized study. All in all, 310 patients with a history of HF (left ventricular ejection fraction ≤40%; or at least one episode of clinical HF with elevated NT-proBNP ≥450 ng/L) and implanted with a cardioverter defibrillator enabling HeartLogic index calculation will be included across 10 French centers. The HeartLogic index will be monitored remotely on a weekly basis for 12 months and in case of HeartLogic index ≥16, the local investigator will contact the patient for assessment and adjust HF treatment as necessary. The primary endpoint is unscheduled hospitalization for HF. Secondary endpoints are all-cause mortality, cardiovascular death, HF-related death, and unscheduled hospitalizations for ventricular or atrial arrhythmia. Blood samples will be collected for biobanking, and quality of life will be assessed. A blind and independent committee will adjudicate the events. Conclusions The HeartLogic French Cohort Study will provide robust real-world data on HF hospitalization in a cohort of patients managed with the HeartLogic algorithm allowing preemptive treatment of congestion. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific

BACKGROUND: The prevalence of atrial fibrillation(AF) and diabetes mellitus is rising to epidemic proportions. We aimed to assess the impact of diabetes on the management and outcomes of patients with AF.METHODS: The EORP-AF General Long-Term Registry is a prospective, observational registry from 250 centres across 27 European countries. Outcomes of interest were as follows: i)rhythm control interventions; ii)quality of life; iii)healthcare resource utilisation; and iv)major adverse events.RESULTS: Of 11,028 patients with AF, the median age was 71 (63-77) years and 2537 (23.0%) had diabetes. Median follow-up was 24 months. Diabetes was related to increased use of anticoagulation but less rhythm control interventions. Using multivariable analysis, at 2-year follow-up, patients with diabetes were associated with greater levels of anxiety (p = 0.038) compared to those without diabetes. Overall, diabetes was associated with worse health during follow-up, as indicated by Health Utility Score and Visual Analogue Scale. Healthcare resource utilisation was greater with diabetes in terms of length of hospital stay (8.1 (±8.2) vs. 6.1 (±6.7) days); cardiology and internal medicine/general practitioner visits; and emergency room admissions. Diabetes was an independent risk factor of major adverse cardiovascular event (MACE; HR 1.26 [95% CI, 1.04-1.52]), all-cause mortality (HR 1.28 [95% CI, 1.08-1.52]), and cardiovascular mortality (HR 1.41 [95% CI, 1.09-1.83]).CONCLUSION: In this contemporary AF cohort, diabetes was present in 1 in 4 patients and it served as an independent risk factor for reduced quality of life, greater healthcare resource utilisation and excess MACE, all-cause mortality and cardiovascular mortality. There was increased use of anticoagulation therapy in diabetes but with less rhythm control interventions.

BACKGROUND: Cardiac troponins (cTn) have been reported to be predictors for adverse outcomes in atrial fibrillation (AF), patients, but their actual use is still unclear.AIM: To assess the factors associated with cTn testing in routine practice and evaluate the association with outcomes.METHODS: Patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry were stratified into 3 groups according to cTn levels as (i) cTn not tested, (ii) cTn in range (≤99th percentile), (iii) cTn elevated (>99th percentile). The composite outcome of any thromboembolism /any acute coronary syndrome/cardiovascular (CV) death, defined as Major Adverse Cardiovascular Events (MACE) and all-cause death were the main endpoints.RESULTS: Among 10 445 AF patients (median age 71 years, 40.3% females) cTn were tested in 2834 (27.1%). cTn was elevated in 904/2834 (31.9%) and in-range in 1930/2834 (68.1%) patients. Female sex, in-hospital enrollment, first-detected AF, CV risk factors, history of coronary artery disease, and atypical AF symptoms were independently associated with cTn testing. Elevated cTn were independently associated with a higher risk for MACE (Model 1, hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.40-2.16, Model 2, HR 1.62, 95% CI 1.28-2.05; Model 3 HR 1.76, 95% CI 1.37-2.26) and all-cause death (Model 1, HR 1.45, 95% CI 1.21-1.74; Model 2, HR 1.36, 95% CI 1.12-1.66; Model 3, HR 1.38, 95% CI 1.12-1.71).CONCLUSIONS: Elevated cTn levels were associated with an increased risk of all-cause mortality and adverse CV events. Clinical factors that might enhance the need to rule out CAD were associated with cTn testing.

Background Ventricular arrhythmic events are responsible for 50% of death in heart failure but no reliable predictive marker is known to discriminate patients at risk of fatal arrhythmia. Interestingly, familial predisposition has been reported suggesting a role of genetic factors. Purpose Identify genetic markers increasing the arrhythmic risk in heart failure population. Method We prospectively included heart failure patients with left ventricular ejection fraction (LVEF) under 35% and a cardioverter defibrillator in primary prevention in 22 French centres between 2009 and 2017. Patients were followed for 72 months and divided into two groups: cases with an arrhythmic event during follow-up and controls. A Genome Wide Association Study (GWAS) was done. Single Nucleotide Polymorphisms (SNPs) genotyping was performed on Affymetrix Axiom Precision Medicine Research Array plates. To complement the directly genotyped SNPs we performed large-scale imputation based on the Haplotype Reference Consortium European ancestry panel leading to a dataset of 7,5 million of SNPs. Results 332 cases and 567 controls were included (86% men, mean age at implantation 52±11 years). 78% of patients had ischaemic cardiopathy, 20% had dilated cardiomyopathy. Mean LVEF was 27±5%. No statistical difference was found between cases and controls on clinical parameters, biological results, electrocardiographic measures. No locus shows genome-wide significant association (p Conclusion No locus raises genome-wide significance, but several signals with a nominal p-value point to relevant genes and pathways. Replication of the GWAS is ongoing on a cohort of 156 new patients with a less severe cardiopathy implanted with a cardioverter defibrillator in secondary prevention. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Nantes University Hospital

Background Brugada syndrome (BrS) is an inherited arrhythmia syndrome with an increased risk of SCD. While Subcutaneous ICD (S-ICD) is a seductive approach to treat these patients, questions raised on the risk of inappropriate shock in this specific population. Objective The aim of this study was to evaluate the safety and the effectiveness of the S-ICD in BrS patients. Methods We prospectively enrolled 112 BrS patients implanted with S-ICD in 17 European centers. During the screening at least 2 vectors must be suitable but it was not necessary to check for the suitability of the ECG during sodium channel blocker or exercise test. S-ICD indications follow the current guidelines. Results Mean age of patients was 45±13 years, with 95 (85%) males. Implantation was performed in 91 (83%) patients for primary prevention and in 18 (16%) patients for secondary prevention. There is an indication of ICD replacement for 16 patients (14%): 13 lead defect (81%), 1 infection (6%) and 2 ICD end of life (13%). In this cohort, 57 patients (51%) had spontaneous type I BrS, 60 patients (55%) were symptomatic: 10 resuscitated SCD (17%) and 48 (83%) syncope. Implantation was performed under general anesthesia in 79 patients (71%). The mean operation time was 56±19 min. The lead was placed at the left side of the sternum in 102 patients (92%) and at the right side in 9 (8%). Sensing configuration was the primary vector for 46 patients (41%), secondary vector for 57 (51%) and alternative vector for 9 (8%). No complications occurred during implantation. During a mean follow-up of 15.6 months (0–39 months), 6 patients (5%) had at least one appropriate shock (n=9). The rate of appropriate shock was 4.5%/y. All the VF episodes were successfully treated with the first shock. One patient had VF ablation for recurrent VF. Among the 6 patients who received an appropriate shock, 3 (50%) were implanted for secondary prevention and 3 (50%) were implanted for primary prevention including 2 patients with a history of syncope and one asymptomatic patient. Twelve patients (11%) had at least one inappropriate shock (n=22) including 2 patients with respectively 8 and 4 inappropriate shocks due to T-wave oversensing. With the SMART pass system the first patient had no more inappropriate shock for now 2 years. The rate of inappropriate shock was 9%/y. One patient died of myocardial infarction. Five patients (4%) were hospitalized for complications (4 pocket or scar infections and 1 electrode failure). Conclusion Our initial experience showed that S-ICD is efficient to treat VF episode in BrS patients. In this population, the rate of inappropriate shock was 9%/y. In view of these results, S-ICD implantation seems to be efficient to protect BrS patients against SCD. Acknowledgement/Funding Investigator-Sponsored Research program, Boston Scientific

Resume Les antiarythmiques ont une efficacite et des effets secondaires qui varient selon les molecules et la classe pharmacologique a laquelle ils appartiennent. Leur utilisation en medecine d'urgence prehospitaliere et hospitaliere repose sur des regles precises, et ce d'autant plus que leur marge therapeutique est etroite. Parmi ces regles, les principales sont l'appreciation rapide du retentissement hemodynamique, l'identification precise du trouble du rythme, la recherche du facteur declenchant et/ou favorisant, la connaissance de la pharmacocinetique de la molecule utilisee et le respect de leurs associations. Parmi les molecules injectables, l'adenosine triphosphate (Striadyne ® ) garde une place de choix dans le traitement des tachycardies jonctionnelles, le sotalol et l'amiodarone dans le traitement des tachycardies ventriculaires (en respectant rigoureusement les precautions d'injections). Les associations d'antiarythmiques sont a proscrire dans l'urgence. La cardioversion par choc electrique externe est reservee aux etats de choc et/ou aux echecs du traitement medicamenteux. Le respect des regles de prescription permet, dans une situation precaire aux urgences ou en prehospitalier, de passer un cap avant de confier le patient au cardiologue pour la suite de l'exploration et du traitement de fond de ce trouble du rythme.

Clinically discovering a systolic murmur is frequent among the young military population. When this murmur does not sound benign, a transthoracic echocardiography (TTE) is made to detect any cardiopathy, which could cause sudden cardiac death. The aim of this study was to evaluate the interest of systematic TTE in the assessment of any cardiac systolic murmur (CSM) among militaries.We ran a retrospective monocentric study in the "Clermont-Tonnerre" military hospital in Brest. We included all patients sent for TEE, aged 15 to 30 years old, from the 1st January 2010 until the 31st July 2013.Two hundred and eighty TTES assessing CSM were performed. We found 28/280 (10%) echocardiographic abnormalities: 13 were bicuspid aortic valves (4.6%), 6 were ventricular septal defects (2.15%), 3 were atrial septal defects (1.07%), 4 were mild mitral regurgitations (1.43%), one mild pulmonary stenosis (0.35%) and one aortic stenosis (0.35%). No hypertrophic cardiomyopathy was found. Concerning military expertise, 11 (3.92%) patients among these 28 with abnormal TEE were considered unfit for work or "fit for work with limitations".Assessing a cardiac systolic murmur with TEE lead to the diagnosis of a cardiomyopathy in 10% of the case. This study enhances the importance of systematic TEE when a CSM is detected in the young military, in order to determine if those soldiers can still fulfill their military duty.

Objective: To compare oral anticoagulant treatment (fluindione) started on either the 1st or the 10th day of a low-molecular-weight heparin (enoxaparin) treatment for deep vein thrombosis confirmed by venography. Design: An open, multicenter, randomized study in two parallel treatment groups. Interventions: All patients received enoxaparin, 1 mg/kg s.c. twice daily, and oral fluindione, 20 mg once daily, either beginning on day 1 or on day 10 of the enoxaparin treatment. Enoxaparin was discontinued once the international normalized ratio under fluindione was stable between 2.0 and 3.0 over 2 days. Fluindione treatment was maintained during a 3-month follow-up period. Outcome Measurements: Specific examinations (venography and/or V/Q lung scanning and/or angiography) were performed only in the event of a clinically suspected recurrence of venous thromboembolism during the 3-month follow-up period. All cases were blindly assessed by an independent Reading Committee. Results: A clinically suspected venous thromboembolism was confirmed by objective tests in 1 of 223 patients (group of delayed introduction of fluindione; n = 111). Equivalence was demonstrated between the two treatment schedules (p < 0.0001) for a maximal difference of 10% (90% confidence interval: –2.42 to 0.58). The mean duration of hospitalization was significantly reduced (p = 0.0001) in the group with early introduction of fluindione. The incidence of hemorrhage was comparable between the two treatment groups. Conclusion: Early and delayed introduction of oral anticoagulant treatment in association with subcutaneous enoxaparin in patients with deep vein thrombosis was shown to be equivalent in preventing the recurrence of venous thromboembolism. In patients with early introduction of oral anticoagulant, hospitalization was significantly reduced.

Resume La notion de risque cardiovasculaire global Pour un individu donne, le risque cardiovasculaire global se definit comme la probabilite de survenue d’un evenement vasculaire dans un temps donne en fonction de ses facteurs de risque consideres dans leur ensemble. Il existe des inegalites d’un patient a l’autre qui conduisent a hierarchiser les patients en fonction de l’importance de leur risque. Pour reduire le risque cardiovasculaire global De grands essais cliniques ont montre l’efficacite des statines en prevention primaire et secondaire de sorte que leur prescription est devenue quasi systematique chez les patients ayant une cardiopathie systemique ou un risque cardiovasculaire global eleve. Les statines auraient en outre d’autres effets sur divers parametres de vulnerabilite des plaques d’atherome. En pratique La prise en charge d’une hypertension arterielle est imperative quels que soient les autres facteurs de risque. La prevention des evenements coronaires beneficie de l’adjonction d’une statine, qui entraine une baisse du LDL C meme chez des patients a bilan lipidique initial normal.

Introduction L’oligoarthrite est une atteinte inflammatoire de 2 ou 3 articulations. Elle a de nombreuses etiologies qu’il faut s’acharner, a l’aide de l’anamnese, de la clinique, des examens paracliniques, a rechercher, gage d’un traitement etiologique adapte. Nous rapportons ici une etiologie exceptionnelle d’oligoarthrite associee a une eruption cutanee. Observation Monsieur T., educateur canin de 50 ans, consulte pour fievre depuis 72 heures associee a une douleur du coude gauche depuis 24 heures. Ses comorbidites sont une silicose, un asthme, des lombalgies chroniques, une gonarthrose bilaterale traitees par formoterol, montelukast, ebastine, budesonide, sulfate de terbutaline. L’examen retrouve une fievre a 40 °C, une arthrite du coude gauche et du genou droit mais ni souffle cardiaque, ni lesion cutanee. Le lendemain, il presentera trois lesions d’erytheme annulaire centrifuge. Devant cette oligoarthrite aigue febrile associee a un syndrome inflammatoire biologique avec une hyperleucocytose et l’absence de signes radiographiques notables, nous realisons un bilan etiologique. L’analyse du liquide articulaire du coude retrouve un liquide inflammatoire avec une predominance de PNN, sans microcristaux ni germe a l’examen direct et a la culture avec une PCR ARN 16S negative. Les serologies : Campylobacter, Yersinia pseutobuberculosis et Y. enterocolitica, Chlamydia trachomatis et C. pneumoniae, Mycoplasma pneumoniae, Francisella tularensis, Treponema pallidum, Borrelia burgdorferi, VIH, parvovirus B19, hepatitis B et C virus reviennent negatives. De meme que les marqueurs de rhumatisme inflammatoire (AAN positifs au 1/320e mouchetes sans specificite, anti-CCP, FR et ANCA negatifs). L’origine iatrogene est ecartee. C’est apres 7 jours de culture qu’une des cinq hemocultures revient positive a Capnocytophaga canimorsus. Cette infection est traitee par ceftriaxone (2 g IV/jour, 7 jours) puis levofloxacine (500 mg × 2/jour per os 4 semaines) avec efficacite. Le patient ne presente pas de facteur majeur d’immunodepression. Seul un diabete a ete decouvert, mais il a une exposition professionnelle patente avec notion de lechage de plaies du visage par ses chiens. Discussion C. canimorsus est un Bacille gram negatif [1] a culture lente [1] . Difficile a identifier [1] , on peut dorenavant s’aider de la PCR universelle [1] ou de la spectrometrie de masse. Contrairement aux autres Capnocytophaga d’origine bucco-dentaire et frequemment opportunistes, C. canimorsus est un germe commensal de la gueule du chien mais aussi du chat et du lapin qui se transmet par morsure, griffure et autres contacts [1] . Son traitement repose sur une antibiotherapie notamment par penicilline. T. Butler a recense 484 cas dans sa revue de la litterature en 2015 [1] , il s’agit en general d’hommes [1] de plus de 50 ans [1] en contact avec des chiens ou des chats [1] , presentant comme autres facteurs de risque une splenectomie [1] ou une asplenie fonctionnelle [1] et/ou une consommation excessive d’alcool [1] . Cependant, la plupart des cas decrits sont survenus chez des patients apparemment en bonne sante [1] . L’infection par C. canimorsus associe des symptomes varies, domines toutefois par le sepsis et la meningite [1] , et se place dorenavant juste derriere Pasteurella multocida pour les infections apres morsure de chien et Streptococcus pneumoniae pour le sepsis chez les splenectomises [1] . Par contre, l’atteinte rhumatologique reste exceptionnelle : une spondylodiscite chez un homme de 54 ans [2] , une bi-arthrite des genoux chez un homme de 59 ans a distance d’une arthroplastie [5] , une mono-arthrite du genou avec exantheme chez un homme de 59 ans apres arthroplastie [4] et une mono-arthrite de la premiere metatarso-phalangienne chez un homme de 67 ans [3] . Chez tous [2] , [3] , [4] , [5] , un contact avec un chien a ete retrouve. Cette observation a ete l’occasion de recenser sur les 15 dernieres annees les infections a C. canimorsus diagnostiquees dans notre CHRU soit 5 cas : une endocardite avec purpura, deux plaies infectees, une spondylodiscite et l’oligoarthrite avec erytheme annulaire centrifuge. Chez quatre, un contact avec un chien a ete retrouve et chez un, un contact avec un chat. Trois patients presentaient un diabete et un etait splenectomise. Conclusion Nous rapportons ici une cause inhabituelle d’oligoarthrite avec eruption cutanee sous la forme d’erythemes annulaires centrifuges. Il s’agit de l’expression clinique rare d’une bacteriemie a C. canimorsus, chez un patient en bonne sante apparente mais ayant une exposition patente. Cette observation rappelle la necessite d’un bilan exhaustif des oligoarthrites incluant la PCR16S sur le liquide de ponction, la pratique d’hemocultures systematiques sur milieu performant cultivees au moins 7 jours.

International audience; OBJECTIVE: To analyse coronary stents with multislice spiral computed tomography (MSCT) in comparison with coronary angiography. PATIENTS AND METHODS: 310 patients referred for conventional coronary angiography underwent MSCT on the next day (16 x 0.75 mm cross section, 420 ms rotation, 110 ml contrast agent intravenously at 4 ml/s). Two independent blinded reviewers analysed the MSCT. RESULTS: 143 patients had previous stenting (232 stents) and 190 (82%) of the 232 stents were detected. Intrastent lumen was interpretable in 126 (64%) of the detected stents. Lumen interpretability depended on stent diameter: for stent diameter > 3 mm, 81% of lumens were interpretable, as against 51% with < or = 3 mm stent diameter (p < 0.001). Restenosis detection likewise depended on stent diameter: with small stents (< or = 3 mm), sensitivity and specificity of MSCT were 54% and 100%, respectively; positive and negative predictive values were 100% and 94%. For stents with > 3 mm diameter, corresponding values were 86%, 100%, 100%, and 99%. CONCLUSION: 16 slice MSCT allows analysis of in-stent lumen in about half of all stented angioplasties. It performs better when stent diameter is more than 3 mm and may offer a non-invasive alternative to conventional coronary angiography for monitoring stented coronary arteries. Technical progress may improve interpretability and hence increase the yield of MSCT in this application.

Physicians can aid their patients' smoking cessation by providing psychological support, advice, behavioral strategies, and drugs. Success depends on appropriate management, including selection of the right moment to begin treatment and an understanding of the development of the withdrawal syndrome, smoking urges, and the possibility of failure. The standard pharmacological treatment for nicotine dependence uses different forms of nicotine substitutes and bupropion, while we await data about other drugs currently under study. The score on the "simplified" Fagerström questionnaire usually determines the initial nicotine dose. Six forms of nicotine substitutes are available. They provide either prolonged nicotine release (transcutaneous patches) that prevents withdrawal symptoms, or rapid release through the buccal and nasal mucosa (chewing gum, suckers, inhalers and nasal sprays) to anticipate the positive effects represented by cigarettes and the urges occurring during withdrawal. The efficacy of these substitutes, widely studied, is approximately twice that of placebo. Their use is no longer contraindicated in patients with heart disease, when necessary. Bupropion should be used in treating nicotine dependence either as a first-line treatment, or if nicotine substitutes (150 mg/d the first week, 300 mg/d thereafter) fail. The combination of bupropion and nicotine substitutes can be considered, either from the outset for heavy or very heavy smokers, or afterwards, if withdrawal symptoms or urges to smoke persist in subjects treated by only one of these two drug classes. One of the new drugs under evaluation is rimonabant, the first representatives of a new class of drugs, selective CB1 endocannabinoid receptor antagonists. Promising results about its use in smoking cessation were released in 2004.

The authors carried out a retrospective study of short and long-term mortality after aortic valve replacement and assessed the quality of life by the IRIS scale in patients over 75 years of age operated for severe aortic stenosis at the University Hospital of Brest between June 1990 and March 1995. The hospital files of 110 consecutive patients (71 women, 39 men; average age 78 +/- 2 years, range 75-85 years) were studied. The pre- per- and postoperative data was studied. Each survivor was contacted by telephone during the year 2000 and a health and IRIS quality of life questionnaire was sent to them. Precise information about patients who had died was obtained from the family and/or medical practitioner. In the preoperative period, 30.9% of patients had left ventricular failure. The average aortic valve surface area was 0.53 +/- 0.12 cm2. Of the patients who underwent coronary angiography (60%), one third had significant coronary lesions. Coronary artery bypass surgery was associated with aortic valve replacement in 10% of cases. Biological prostheses were used in 108 patients. The operative mortality was 8.2%. One year, 5 year and 10 year survival rates were 89.9%, 75.5% and 33.3% respectively. Of the survivors, 16.7% were in institutional care and 83.3% lived at home. A total of 77.8% were readmitted to hospital, about half of them for cardiac problems. Cardiac treatment was prescribed for 97% of patients. The quality of life questionnaire was completed by 35 patients: the quality of life was better than average in nearly 83% of these patients. Aortic valve replacement for aortic stenosis in patients over 75 years of age improves life expectancy which is almost the same as that of the normal population of the same age, and improves the quality of life by restoring functional autonomy, enabling the majority of them to live in their own houses most of the time.

Syncope is a common symptom of clinical practice which raises the problem of the differential diagnosis of other causes of loss of consciousness and a logical diagnostic strategy to avoid systematic prescription of expensive, invasive and often valueless investigations. The aim of this article is to propose a diagnostic procedure for syncopes in adults based on recent recommendations and the value of currently available diagnostic tests.

Since 1989, the French healthcare politic has introduced a national healthcare information system, based on the hospitalization description by diagnosis and procedure codes according to a standardized format derived from Disease Related Groups. The medical interest of such an information database is limited by the data quality, and the coding task remains difficult and constraining for physicians. We report the results of a preliminary study, whose objective was to measure the effects on information quality of context-oriented coding forms. In a French hospital, coding forms were elaborated for frequent and standardized clinical situations in the cardiology field during the 1998-year. The comparison of the a 3-year activity description in the concerned unit showed an improvement in the mean number of target procedure codes, the choice of the principal diagnosis, the precision of data and the abstract classification, despite a loss in diagnostic codes. Coding controls by expert confirmed the data quality improvement. The concept of context-oriented coding aid can be extended to other medical disciplines but the paper supply limits the aid content, and leads to problematic maintenance updating. The opportunity to integrate the coding forms in a unique digital library using a semantic network structure is discussed.

Left ventricular-based (LV) pacing is considered an effective adjunct to pharmacological treatment in patients with severe chronic heart failure (CHF) [1, 2]. However, many questions related to this new therapeutic option remain open. One of these is the utility of acute hemodynamic-angiographic evaluation prior to the permanent implantation. The aim of this review is to attempt to summarize our knowledge on this topic.

Factor V Leiden is associated with an increased risk of venous thrombosis and myocardial infarction in young women, but not in men in this latter case. The aim of this study was to evaluate the prevalence of this mutation in patients with myocardial infarction but normal coronary angiography. We compared 3 groups of patients: one group consisted of 107 patients with premature myocardial infarction but no significant coronary artery stenosis; another group of 244 patients with myocardial infarction and significant coronary artery stenosis; a third group of 400 healthy controls. Factor V Leiden was found in 13 patients (12.1%) who had a myocardial infarction without significant coronary artery stenosis, 11 patients (4.5%) who had a myocardial infarction with significant coronary artery stenosis (p = 0.01) and in 20 controls (5%) (p = 0.01). Odds ratio associated with factor V Leiden were respectively 2.93 (CI95: 1.18-7.31 ) and 2.63 (CI95: 1.19-5.78) when we compared myocardial infarction patients without significant coronary artery stenosis to controls or to patients with significant coronary artery stenosis. In myocardial infarction patients without significant coronary artery stenosis, prevalence of factor V Leiden is significantly higher than in controls. This new finding supports the hypothesis that thrombosis plays a key role in this selected situation.

Cardioversion of atrial fibrillation by an endocavitary electrical shock was first proposed during the 1980s. The authors studied the efficacy of this technique at short and medium term in a population of 36 patients (28 men and 8 women) in whom atrial fibrillation persisted despite attempts to reduce it by antiarrhythmic drugs and external electrical cardioversion. The immediate success rate was high : 34 out of 36 patients (94%) and, at medium term, the number with sinus rhythm was comparable to that of studies evaluating the medium-term efficacy of external electrical cardioversion; 19 out of 33 patients (57%) were in sinus rhythm at 6 months and 9 out of 27 patients (33%) at 12 months. These results seem to justify attempts at internal atrial defibrillation in patients in whom the other two techniques of cardioversion have failed. Its use as the method of first intention could be proposed if the profile of "resistant" patients to classical techniques was known, which is unfortunately not presently the case.

The aim of this retrospective study was to assess short and long-term mortality and morbidity after radiofrequency ablation of the atrioventricular junction in patients with supraventricular arrhythmias resistant to treatment. This cooperative series included 91 patients (47 men, mean age 68 +/- 9 years). The arrhythmia was paroxysmal in 56% of cases. The mean duration of symptoms was 67 +/- 61 months and 45 patients (49.4%) were in the NYHA Classes III and IV. An escape rhythm was present in 58 patients with a mean frequency of 39 +/- 9/min. Early complications were observed in 5 patients (venous thromboses, pulmonary embolism, mild pericardial effusion and haemothorax). The hospital mortality was 4 patients (4.4%). Death was of cardiac origin in 1 case (cardiac failure). The mean follow-up of patients was 14.5 +/- 8.6 months. Eleven patients died during this period, 8 of cardiac causes: cardiac failure (3 cases), sudden death (3 cases), thrombosis of a valve prosthesis (1 patient) and major electrolyte disturbances causing loss of stimulation in 1 case. Six patients had recurrences. Long-term morbidity was either related to cardiac pacing (3 cases) or cardiac failure (3 cases). Thirteen patients were in NYHA Classes III or IV at the end of follow-up. The authors conclude that radiofrequency ablation at the atrioventricular junction is an effective method of treating resistant supraventricular arrhythmias. Complications are not frequent but mortality appears to be high, probably due to the presence of advanced cardiac disease in the majority of cases. Sudden death seems to be rare and unrelated to pacing defects.

The authors report the case of a 21 year old woman with a congenital long Q7 syndrome who had several syncopal attacks at least one of which was caused by torsades de pointe. This sudden complication was attributed to the simultaneous prescription of Spiramycine and Mequitazine over a 48 hour period. These two drugs are not considered to be predisposing factors for torsades de pointe despite the fact that they belong to two families of drugs which can trigger this type of arrhythmia. The withdrawal of this treatment led to the complete regression of the syncopal episodes with a follow-up of two years and a significant shortening of the initial QTc interval which remained, nevertheless, longer than normal. This case underlines the potential risks of drug associations of these two families of drugs, especially in patients with the congenital long Qt syndrome.

Mid-term outcome of the underlying escape rhythm developed after radiofrequency ablation of the atrio-ventricular junction was studied in 50 consecutive patients (28 women and 22 men with a mean age of 66.2 +/- 9.6 years). The escape rhythm was assessed immediately after ablation and after 13.7 +/- 8 months. At the end of ablation: an escape rhythm was present in 38 patients (76%), with a mean rate of 40.7 +/- 9.7 beats/min and a QRS morphology identical to the preablation QRS morphology in 22 patients (58%). At follow-up: an escape rhythm was present in 37 patients (74%), with a slower mean rate of 36.4 +/- 6.8 beats/min (p0.05) and an unchanged QRS morphology in 87.5% of the patients. Patients presenting with an escape rhythm at follow-up were more frequently found to have a postablation escape rhythm (p0.01). Escape rhythm presence at follow-up was not influenced by age, presence of a cardiac disease, continuation of an antiarrhythmic treatment after ablation, use of a bilateral approach for ablation or number of radiofrequency applications.after abrupt inhibition of the stimulation, an escape rhythm was present only in 74% of the patients 13.7 +/- 8 months after atrio-ventricular junction radiofrequency ablation. QRS morphology was identical to the preablation morphology in 57% of the patients.

The management of acute myocardial infarction has been transformed over the last thirty years by a number of therapeutic innovations. The authors decide to compare the outcomes of three cohorts of unselected patients admitted to hospital at 10 year intervals, to evaluate the impact of these innovations on morbidity and mortality. Six hundred and sixty one patient admitted to the Coronary Care Unit for acute myocardial infarction were included: Group I comprised 223 patients admitted consecutively during the period 1972-1973; Group II comprised 243 patients admitted between 1982-1983 and Group III comprised 195 patients admitted between 1992-1993. The average age was comparable, about 65 years, in the 3 groups, although there were gender differences. Taking into consideration earlier hospital admission, the in-hospital mortality decreased from 25% in Group I to 21.8% in Group II and to 15.4% in Group III (p0.05 between the first 2 groups and the third group). This decrease in mortality is even greater in anterior wall infarction and is observed in all ages. Similarly to selected patients in large scale randomised clinical trials, the ordinary "run of the mill" patient has also benefited from therapeutic innovations over the last ten years.

The one year results of three techniques of bypass grafting of the artery of the left border of the heart were compared in a retrospective study in 120 patients all undergoing left anterior descending bypass grafting with an internal mammary artery. Group I comprised 38 consecutive patients: the left border artery was bypassed with a venous graft. Group II comprised 49 consecutive patients who had the left border artery bypassed by an internal mammary artery in situ. Group III comprised 33 consecutive patients who had the left border artery bypassed by an internal mammary graft issuing from a Y-shaped construction (right internal mammary artery as a free graft reimplanted into the left internal mammary artery). The operative mortality, morbidity and functional results were comparable in the three groups. The rate of angiographic success of the left border artery graft at one year was: 65.7% in group I, 89.5% in group II and 87.8% in group III. The one year patency of internal mammary artery grafting of the artery of the left border was higher than that of venous grafts (p0.05).

Antiarrhythmic drugs are widely used in atrial fibrillation. The demonstration of severe pro-arrhythmic effects in recent years has led to the reappraisal of their indications in this pathology. Antiarrhythmic agents have three roles: reduction of the fibrillation, maintenance of sinus rhythm and, in case of failure, control of the ventricular response. In the first indication, although intravenous injection of Class Ic antiarrhythmics is effective in 70% of cases, there is an alternative: electrical cardioversion, which is effective in 90% of cases with the transthoracic method when a certain number of technical conditions are respected. The success rate is even better with endocavitary defibrillation. Sinus rhythm is sustained in only 25% of patients at one year with placebo and in 50% of patients with antiarrhythmic therapy. The alternatives in this indication are few at present and consist in right atrial pacing in cases of vagal fibrillation and biatrial pacing for resynchronizing the activation of the two atriae when there is a major interatrial conduction defect. The control of the ventricular response, in cases of permanent atrial fibrillation, is usually reserved to digitalis, betablockers, amiodarone and some calcium antagonists. They are often inadequate and an alternative is radiofrequency catheter ablation of the atrioventricular node, which requires permanent ventricular pacing. In conclusion, there are a few alternatives to antiarrhythmic drug therapy in atrial fibrillation, but they are relatively ineffective in maintaining sinus rhythm.

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In human atrial fibers, the action potential undergoes a major developmental change in shape in the months immediately after birth. Transient potassium outward currents, which may affect the shape of the action potential, have been studied using a whole cell voltage-clamp technique with single cells from the atria of young patients aged 3-60 mo. Transient outward current (I(to)) amplitude was measured as the difference between the peak current and the steady-state outward current (I(late)) at the end of the voltage step. The density of I(to) was significantly reduced in adult diseased cells (n = 18) compared with normal cells (n = 21) in a large range of potential and absent in young diseased cells (n = 13). Furthermore, the I(late) recorded in young cells was significantly greater (23.7 +/- 5.74 pA/pF at 60 mV) than in adult normal cells (12.71 +/- 2.25 pA/pF at 60 mV), whereas I(late) was not significantly different between both groups of adult cells. Nevertheless, a 4-aminopyridine-sensitive I(to) has been recorded in young cells. A decrease in the frequency of clamp steps (from 0.1 to 0.01 Hz) did not reactivate a I(to) in young cells. This absence of 4-aminopyridine-sensitive Ito in young cells probably results from either a normal developmental change of this current or from pathological alterations like those described in adult diseased atria.

We have prospectively evaluated 6 patients admitted for a severe heart failure in alcoholic patients with dilated cardiomyopathy. We concluded that complete abstinence results in a short-term clinical improvement, associated to a significant increase in left ejection fraction.

The authors report the case of a 68 year old woman who underwent implantation of a Greenfield vena caval filter for recurrent pulmonary embolism. Migration of the filter out of the vena cava into the perivenal fat was discovered two years later during another embolic episode. One of the spokes of the filter had migrated into the iliac fossa. This case illustrates two possible complications of caval filters: rupture and migration. The increasing number of cases reported in the literature indicates the necessity of keeping a register of the complications encountered with different models to avoid the most dangerous ones.

Out of 3,171 consecutive patients referred for coronary angiography, 240 were selected on the following criteria: recent primary myocardial infarction, single vessel coronary disease, no angioplasty or coronary surgery after the angiography which was performed 20 to 90 days after the onset of myocardial infarction. The patients were divided into 2 groups according to whether the artery responsible for infarction was patent (Group I: 115 patients) or not (Group II: 125 patients). The left ventricular ejection fraction was significantly higher in Group I (58 +/- 10.8%) than in Group II (53.7 +/- 11.3%) and end systolic and end diastolic left ventricular volumes were greater in Group II (51.8 +/- 22 ml/m2 and 88 +/- 22 ml/m2 respectively). Long-term follow-up (56 +/- 25 months in Group I and 61 +/- 26 months in Group II) was possible in 112 patients in Group I and 123 patients in Group II. Of the 7 patients who died in group II, 4 deaths were of cardiac origin; in addition, 2 cases of sustained ventricular tachycardia were observed in this group. None of the 6 deaths observed in Group I was of cardiac origin and there were no cases of ventricular tachycardia (p = 0.05). The functional status was identical in the two groups at the end of the study. These results suggest that the patency of the coronary artery responsible for myocardial infarction at a distance from the acute event is associated with better left ventricular function and a better long term prognosis.

Increased sympathetic tone is one physiopathological mechanism of vasovagal syncope. In this case, betablocker therapy is logical. The reports in the literature suggest that the head-up tilt test can reliably reproduce vasovagal syncope. Ten patients (4 men and 6 women, mean age 59 +/- 18 years) who suffered from recurrent vasovagal syncopes (2 to 10 attacks in 6 patients and more than 10 in the other 4) with a positive initial head-up tilt test (syncope or severe dizziness with marked hypotension after a maximum of 40 minutes at 60 degrees) were treated with atenolol (200 mg daily in 7 cases and 100 mg daily in the other 3). A second head-up tilt test was performed 15 +/- 6 days later under betablocker therapy; this test was negative in 7 and remained positive in 3 cases. Irrespective of the result, the 10 patients followed the same therapy at the same dosage. After 9 +/- 5 months, 3 patients had another syncopal attack; 2 stopped taking their medication and the third patient continued the betablocker because there was a marked reduction in the frequency of his attacks. There were no further syncopal episodes during follow-up of the other 7 patients. The medium-term efficacy could not be predicted from the results of the second head-up tilt test. The following conclusions may be drawn from this study: The head-up tilt test becomes negative in 70% of cases after introducing betablocker therapy, assuming a 100% reproductivity. This treatment is effective in over half the patients at medium term and should be considered in patients with recurrent vasovagal syncope.

From 1985 to november 1989, 270 patients underwent sequential anastomosis with left internal mammary artery (LIMA) on left descending artery (LDA) and diagnonal artery (DA). The first 120 cases have 100% one year follow-up. The perioperative status was: angina stage III or IV: 59%; myocardial infarction (MI): 45%, stenosis of 3 vessels: 52.5%; stenosis of main coronary artery: 10.8%. 2.25 anastomoses were performed per patient. Side-to-side anastomosis (kissing) were not diamond anastomoses but axial and longitudinal. The use of fibrin gllude provides regular curves of the graft between anastomosis. Mortality was 0.8%, morbidity was: MI: 4.2% (2 small infarcts in anterior vessels, 3 others in non-grafted vessels); mediastinitis: 1%; severe bleeding (reoperation): 1%. At one year 93% of patients are free from angina and 71 patients underwent angiographic assessment (145 LIMA anastomosis). Results are as follow: side-to-side anastomosis patency: 98.5%; distal anastomosis obliteration: 3%; LDA anastomosis patency: 95.7% overall sequential anastomosis patency: 97.6%. These results have led our cardiologist in Brest to naturally prefer a surgical approach than percutaneous angioplasty when LDA and DA are involved.

The authors report the case of a 28 year old alcoholic who was admitted to hospital for cardiac failure in 1982 due to a dilated cardiomyopathy. The clinical and paraclinical signs disappeared after cessation of alcohol intake. Three years after abstaining from alcohol, the electrocardiogram, echocardiogram and isotopic ventriculography are normal. This case illustrates the necessity of absolute cessation of alcohol intake in patients with dilated cardiomyopathies.

The cause of brief syncopes is discovered in only two-thirds of the cases at most. The purpose of this study was to quantify the value of the head-up tilt test in patients whose syncope remained "causeless" after a "conventional" investigation. Forty-nine patients entered the study on the following criteria: at least one syncope, no conduction disturbances or normal electrophysiological study, physiological response to carotid sinus massage, absence of postural hypotension and assessable tilt test. The head-up tilt test was performed under blood pressure and electrocardiographic monitoring in three stages: dorsal decubitus during 20 min, 60 degrees tilting during 20 min and, if nothing happened, isoprenaline injection. The test was positive (i.e. produced syncope or at least lipothymia) in 12 patients (24.5 per cent). In all cases the loss of consciousness was associated with a deep fall in blood pressure, but prolonged ventricular pause never occurred (2 patients had bradycardia at about 30 beats/min). The head-up tilt test is a non-invasive examination which in one-quarter of the cases provides a diagnosis of vasovagal syncope when no other diagnosis could be made; it reproduces the syncope, which is rarely done by other investigations, and it deserves to be include in the evaluation of unexplained syncopes.

Introduction et but de l’etude Si la suralimentation chronique predispose a l’obesite et au syndrome metabolique, elle suspecte d’avoir per se des effets metaboliques deleteres. Le but de ce travail etait d’etudier, chez des volontaires sains, les effets d’une suralimentation glucidique de 4 jours (+ 75 % de la depense energetique journaliere (DEJ)) sur le metabolisme glucido-lipidique et certaines fonctions cardio-vasculaires (CV). Materiel et methodes 12 volontaires sains ont ete randomises en 2 groupes : un groupe temoin (T) (2H et 4F, 43,8 ± 2,6 ans, IMC : 22,7 ± 0,5 kg/m 2 ) et un groupe suralimente (S) (1H et 5 F, 43,8 ± 2,6 ans, IMC : 22,1 ± 0,6 kg/m 2 ). Le groupe S recevait pendant 4 j consecutifs dans notre unite un regime representant 175 % de la DEJ calculee comme 1,4 fois la DER (calorimetrie indirecte). Le groupe T poursuivait son alimentation usuelle. Chaque sujet a ete soumis a une seule exploration. La sensibilite a l’insuline a ete evaluee par le debit de perfusion du glucose (DPG) au cours d’un clamp euglycemique hyperinsulinemique a 3 paliers successifs de 90 min (debits d’insuline : P1 = 0,2 ; P2 = 0,4 et P3 = 1 mU/kg/min) ; l’oxydation des substrats a ete quantifiee par calorimetrie indirecte, la lipolyse par les dosages du glycerol plasmatique et interstitiel et des acides gras libres (AGL) plasmatiques. La pression arterielle moyenne (PAM), la frequence cardiaque et la vasorelaxation sous-cutanee non endothelium dependante (en reponse a l’hyperthermie locale) (technique du laser-doppler) ont ete mesurees a chaque palier d’insulinemie. Resultats L’insulinemie etait comparable entre les groupes T et S au cours du clamp (P1 : 17,6 ± 2,2 vs 16,5 ± 0,9 NS ; P2 : 30,9 ± 2,9 vs 29,7 ± 2,5 NS ; P3 : 70,1 ± 5,9 vs 75,2 ± 5,4 mU/l). La suralimentation a induit une baisse de la DPG au 3 e palier d’insulinemie (9,45 ± 0,92 vs 12,31 ± 0,87 mg/kg/min, p Conclusions La suralimentation glucidique breve induit chez des volontaires sains une insulino-resistance et une inhibition de l’oxydation lipidique associee a une augmentation de la vasorelaxation non endothelium dependante, probablement secondaire a une activation sympathique dont temoigne l’augmentation de la frequence cardiaque.