Incidence and outcomes of infective endocarditis after transcatheter aortic valve implantation versus surgical aortic valve replacement.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (AVR) in aortic stenosis (AS). Infective endocarditis (IE) in patients with prosthetic heart valves is associated with significant morbidity and mortality. Data on the incidence, risk factors, and outcomes of IE after TAVI are conflicting. We evaluated these issues in patients with percutaneous TAVI vs. isolated surgical AVR (SAVR) at a nationwide level. METHODS: Based on the administrative hospital discharge database, the study collected information for all patients with aortic stenosis treated with AVR in France between 2010 and 2018. RESULTS: A total of 47 553 patients undergoing TAVI and 60 253 patients undergoing isolated SAVR were identified. During a mean follow-up of 2.0 years (median (25th to 75th percentile) 1.2 (0.1-3.4) years), the incidence rates of IE were 1.89 (95% confidence interval (CI) 1.78-2.00) and 1.40 (95% CI 1.34-1.46) events per 100 person-years in unmatched TAVI and SAVR patients, respectively. In 32 582 propensity-matched patients (16 291 with TAVI and 16 291 with SAVR), risk of IE was not different in patients treated with TAVI vs. SAVR (incidence rates of IE 1.86 (95% CI 1.70-2.04) %/year vs 1.71 (95% CI 1.58-1.85) %/year respectively, relative risk (RR) 1.09, 95% CI 0.96-1.23). In these matched patients, total mortality was higher in TAVI patients with IE (43.0% 95% CI 37.3-49.3) than in SAVR patients with IE (32.8% 95% CI 28.6-37.3; RR 1.32, 95% CI 1.08-1.60). DISCUSSION: In a nationwide cohort of patients with AS, treatment with TAVI was associated with a risk of IE similar to that following SAVR. Mortality was higher for patients with IE following TAVI than for those with IE following SAVR.

Long-term prognosis of patients diagnosed with Brugada syndrome: Results from the FINGER Brugada Syndrome Registry.

BACKGROUND: Brugada syndrome is characterized by ST-segment elevation in the right precordial leads and an increased risk of sudden cardiac death (SCD). Fundamental questions remain on the best strategy for assessing the real disease-associated arrhythmic risk, especially in asymptomatic patients. The aim of the present study was to evaluate the prognosis and risk factors of SCD in Brugada syndrome patients in the FINGER (France, Italy, Netherlands, Germany) Brugada syndrome registry. METHODS AND RESULTS: Patients were recruited in 11 tertiary centers in 4 European countries. Inclusion criteria consisted of a type 1 ECG present either at baseline or after drug challenge, after exclusion of diseases that mimic Brugada syndrome. The registry included 1029 consecutive individuals (745 men; 72%) with a median age of 45 (35 to 55) years. Diagnosis was based on (1) aborted SCD (6%); (2) syncope, otherwise unexplained (30%); and (3) asymptomatic patients (64%). During a median follow-up of 31.9 (14 to 54.4) months, 51 cardiac events (5%) occurred (44 patients experienced appropriate implantable cardioverter-defibrillator shocks, and 7 died suddenly). The cardiac event rate per year was 7.7% in patients with aborted SCD, 1.9% in patients with syncope, and 0.5% in asymptomatic patients. Symptoms and spontaneous type 1 ECG were predictors of arrhythmic events, whereas gender, familial history of SCD, inducibility of ventricular tachyarrhythmias during electrophysiological study, and the presence of an SCN5A mutation were not predictive of arrhythmic events. CONCLUSIONS: In the largest series of Brugada syndrome patients thus far, event rates in asymptomatic patients were low. Inducibility of ventricular tachyarrhythmia and family history of SCD were not predictors of cardiac events.

[Non-antiarrhythmic drug therapy for the prevention of atrial fibrillation?]. / Des médicaments non anti-arythmiques peuvent-ils avoir un effet préventif sur la fibrillation auriculaire?

In atrial fibrillation (AF), the absence of a clear benefit of a rhythm-control strategy over a rate-control strategy seen in recent trials may be due to the fact that many of the usual antiarrhythmic strategy have significant weaknesses. Besides research efforts to improve the efficacy and safety of conventional antiarrhythmic agents, therapies directed 'upstream'of the electrical aspects of AF, towards the underlying anatomical substrate and atrial remodelling, have been proposed as new pharmacological therapeutic approaches. Potential upstream therapies for AF comprise a variety of agents such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), statins, N-3 polyunsaturated fatty acids and steroids. On the basis of experimental data, clinical studies have provided information on the potential of upstream therapy for the prevention of AF across a broad spectrum of cardiovascular patient groups. In patients with heart failure or hypertension, data are sufficient to support the use of ACEI or ARB as treatment that may decrease the risk of AF beyond their other beneficial effects. Similarly, it is highly possible that the use of statin in patients with a recognized indication may be associated with a benefit against AF. However, in most clinical settings, the evidence appears to be insufficient to drive changes in therapy management per se, and large-scale, randomized controlled trials with adequately defined endpoints are still needed. The results from these trials may help to understand the complex mechanisms that lead to AF, and may clarify the benefit-to-risk ratio of these new therapeutic approaches.

An original defibrillation lead implantation to avoid tricuspid prosthesis damage.

We report the case of a 67-year-old woman suffering from Ebstein's disease, who underwent three cardiac operations for bypass, tricuspid prosthesis and pacemaker implantation, and who needed an implantable cardioverter defibrillator for recurrent syncopes related to ventricular tachycardia. Because of the tricuspid prosthesis we chose to implant the defibrillation lead in the inferior vena cava. We collected satisfactory pacing and sensing data and performed a successful defibrillation test during the procedure. This configuration appears to be a safe alternative to conventional implantation in the coronary sinus, as already described in the literature for a few cases.

Implantable loop recorder for recurrent syncopes.

Syncope is a common disorder which may recur and impair the survival and the quality of life of the patients. The objective of the investigation of syncope is to diagnose the cardiac etiology, as mortality rate is high. Implantable loop recorder or insertable cardiac monitor (ICM) is a useful tool to establish a correlation between syncope and heart rhythm. About half of implanted patients complain of a new syncope and about 50% of these patients had cardiac rhythm disturbances on ICM. The most frequent is a sinus bradycardia or sinus arrest, but these results depend on the age of patients, resting electrocardiography (ECG) abnormalities and structural cardiac disease. A classification of the mechanisms of recurrent syncopes has been defined with the results of the ISSUE study, separating the syncope due to primary cardiac arrhythmia from neurally-mediated syncope and from unknown syncope. The analysis of the presyncopal phase on the ICM restored ECG allows physicians to adapt the treatment (antiarrhytmic agents or pacemaker) and optimize the programming of the pacemaker when necessary. It is early recommended to implant the ICM in patients affected with syncope with normal physical examination, normal ECG and without structural heart disease and negative tilt testing. In the presence of cardiac disease, it is recommended to implant ICM after performing an electrophysiological study and tilt testing. In syncope patients with depressed left ventricular ejection fraction, the implantation of an automatic implantable cardiac defibrillator is preferable. The indications of the ICM tend to be extended to new syncope populations such as pediatric patients and epileptic population. Early application of ICM reduces the cost of the investigation of the patients suffering from syncope, especially when the electrophysiological study is avoided. In the future the implantation of the ICM should be early discussed in the Syncope Unit to shorten the duration and the cost of the hospitalizations of the patients with recurrent syncopes.

[Thromboembolism risks in atrial fibrillation]. / Enjeux cliniques morbi-mortalité, risques thromboemboliques.

The atrial fibrillation is linked to an overmortality (x2), except in patients with lone atrial fibrillation. The severity of atrial fibrillation is due to the risk of thromboembolism event, especially stroke. This risk is very high in presence of rhumatismal mitral valve pathology or prosthetic valve. The annual risk of thromboembolism has been evaluated and the CHADS2 score defined from 0 to 6 In function of the CHADS2 score the risk of thromboembolism event is 1.9 to 18.2%/year. Other factors of thromboembolism accident are actually evaluated such as renal insufficiency, proteinuria. The main objective of atrial fibrillation treatment is the prevention of thromboembolism event. The antivitamin K agents proved their efficiency in term of mortality and morbidity justifying to identify the patients at risk of thromboembolism event.

Heart rate variability in mice: a theoretical and practical guide.

The mouse is the animal model principally used to study biological processes in mammals. The mutation, overexpression or knockout of one or several genes can provide insight into human disease. In cardiovascular research, evaluation of autonomic nervous function is an essential tool for a better understanding of the pathophysiological conditions in which cardiomyopathy arises and develops. Analysis of heart rate variability is the least invasive method to evaluate the sympathovagal balance on the sino-atrial level. The need to perform this technique on freely moving mice emerged in the 1990s, but despite previous studies it has been difficult to set up and standardize a common protocol. The multitudes of techniques used, plus subtle differences in methodology, impede the comparison and clear interpretation of results. This article aims to make a survey of heart rate variability analysis and to establish a standardized protocol for the assessment of the autonomic neural regulation of heart rate in mice.

[Evaluation of the cost of complications of automatic implantable defibrillators]. / Evaluation du coût des complications des défibrillateurs cardiaques automatiques implantables.

The automatic implantable defibrillator (AID) has been shown to prevent sudden death but it frequently gives rise to complications. These complications seem to be costly but they do not figure in the economic assessments of AID. From 1989 to 2003, 202 patients (173 men, age 58 +/- 14 years) received consecutively 264 AID in the same centre of implantation. The authors studied the complications of these implantations. The medical indication was secondary (documented spontaneous ventricular tachycardia or fibrillation) in 145 patients (71.8%) and prophylactic in the remaining 57 patients (28.2%). During the 36 month (+/- 35) follow-up, 40.6% patients had an appropriate treatment: 50.3% in the secondary prevention group versus 15.8% in the prophylactic implantation group. The one year, 5 and 15 year survival rates were 99, 88 and 85% respectively. Eighty seven complications were observed resulting in a long term complication in 36.7% of patients. These complications were: inappropriate electric shock, n=24 (27.6%), fractured catheters, n=12 (13.6%), haematomas, n=12 (13.6%), loss of function of the AID, n=10 (11.4%), infection, n=6 (6.8%), pneumothorax, n=7 (8.0%), and others n=16 (18.4%). The cost of these complications was assessed in terms of hospital stay in intensive care (1010.40 euros per day) or in the general cardiology wards (546.70 euros per day). The complications resulted in 502 days of additional hospital stay (5.77 days per complication) with a total cost of 285 655.20 euros (3283.40 euros per complication). The most expensive complications in terms of hospital stay were: infections (24.5 days), fractured catheter (5.75 days), and postoperative haematoma (5.5 days). These results indicate a significant cost of complications which should be indicated in the economic evaluation of AID.

Multitissular involvement in a family with LMNA and EMD mutations: Role of digenic mechanism?

BACKGROUND: Mutations in the EMD and LMNA genes, encoding emerin and lamins A and C, are responsible for the X-linked and autosomal dominant and recessive forms of Emery-Dreifuss muscular dystrophy (EDMD). LMNA mutations can also lead to several other disorders, collectively termed laminopathies, involving heart, fat, nerve, bone, and skin tissues, and some premature ageing syndromes. METHODS: Fourteen members of a single family underwent neurologic, electromyographic, and cardiologic assessment. Gene mutation and protein expression analyses were performed for lamins A/C and emerin. RESULTS: Clinical investigations showed various phenotypes, including isolated cardiac disease (seven patients), axonal neuropathy (one patient), and a combination of EDMD with axonal neuropathy (two patients), whereas five subjects remained asymptomatic. Genetic analyses identified the coincidence of a previously described homozygous LMNA mutation (c.892C-->T, p. R298C) and a new in-frame EMD deletion (c.110-112delAGA, p. delK37), which segregate independently. Analyses of the contribution of these mutations showed 1) the EMD codon deletion acts in X-linked dominant fashion and was sufficient to induce the cardiac disease, 2) the combination of both the hemizygous EMD and the homozygous LMNA mutations was necessary to induce the EDMD phenotype, 3) emerin was present in reduced amount in EMD-mutated cells, and 4) lamin A/C and emerin expression was most dramatically affected in the doubly mutated fibroblasts. CONCLUSIONS: This highlights the crucial role of lamin A/C-emerin interactions, with evidence for synergistic effects of these mutations that lead to Emery-Dreifuss muscular dystrophy as the worsened result of digenic mechanism in this family.

Postcardiac injury syndrome complicating radiofrequency ablation of the atrioventricular node.

Radiofrequency ablation, which is increasingly used in the treatment of cardiac arrhythmia, can be complicated with pericardial effusion and one case of Dressler's syndrome has already been reported after an atrioventricular pathway ablation. This case reports a second case complicating an atrioventricular node radiofrequency ablation procedure.

[Risk stratification in atrial and ventricular arrhythmias]. / Stratification du risque dans les troubles du rythme auriculaire et ventriculaire.

Atrial fibrillation, the most frequent arrhythmia, has a growing incidence with increasing age and the most important complication of the disease is thromboembolic events that may be prevented by antivitamin K. They are the most efficient therapeutic class for the prevention of these events but they are associated with an increased haemorrhagic risk leading to a reduced prescription in general practice. Optimisation of the management should be based on an individual evaluation of the thromboembolic and haemorrhagic risks, taking into account age, the presence of an associated heart disease, hypertension, diabetes, history of cerebrovascular event, history of previous haemorrhagic event and the ability to achieve a stable target INR. The challenge in ventricular arrhythmias lies in identifying a high risk of sudden death, mainly related to ventricular fibrillation. In patients with structural heart disease, left ventricular dysfunction is the strongest predictor of sudden death. Non invasive markers such as non sustained ventricular tachycardia, late ventricular potentials, decreased heart rate variability and baroreflex sensitivity, and repolarization altemans are further elements to assess risk. However, most of these markers have a poor positive predictive value and a low specificity. In patients with normal hearts, genetic predisposition may in the future identify high risk patients. The electrophysiologic study with programmed ventricular stimulation remains a costly and invasive method and only has a strong positive predictive value in ischemic cardiomyopathy. More precise algorithms for risk stratification are thus needed that may help the strategy of therapy with prophylactic implantable cardioverter defibrillator in the future.

[Evaluation after 20 years of a case of Takayasu's disease that presented with aortic regurgitation]. / Evolution après 20 ans d'une maladie de Takayasu Révélée par une insuffisance aortique.

Takayasu's disease is a segmental multifocal affection of medium and large arteries. The diagnosis is based on the association of stenotic and aneurismal lesions of the aorta and its branches secondary to an inflammatory infiltration of the media and adventitia. Cases of aortic regurgitation associated with aneurismal dilatation of the ascending aorta as the presenting features of Takayasu's disease, as in this case, are rare. Histological examination of the aortic wall may help establish the diagnosis by showing signs of aortitis. The other usual arterial lesions are sometimes missing at the initial phase of the disease. A late histological diagnosis may be difficult as the inflammatory lesions tend to be progressively replaced by fibrotic lesions or a banal atheroma.

[Indications for automatic implantable defibrillators in patients with the Brugada syndrome]. / Indications du défibrillateur cardiaque automatique implantable dans le syndrome de Brugada.

Brugada syndrome is a primary electrical cardiac disease characterized by an ST segment elevation in V1-V2 leads on surface ECG and an increased risk of polymorphic ventricular tachyarrhythmia (ventricular tachycardia and/or ventricular fibrillation). The objective of the treatment is to prevent sudden death and it therefore includes in some cases the implantation of an automatic implantable cardiac defibrillator (AICD). In secondary prevention (i.e. after a first episode of resuscitated ventricular fibrillation), the implantation of AICD is mandatory (indication of class 1 level A). In primary prevention (i.e. in patients without documented ventricular fibrillation), the guidelines are not definitively established. We may consider two different clinical situations. First, the patient complains from syncope and this justifies the implantation of an AICD. Second, the patient is asymptomatic and the physician has to discuss the implantation of an AICD. Two parameters should be analysed: the pattern of ECG and the result of right programmed ventricular stimulation. An evident ST segment elevation (>2 mm) is associated with a high risk of sudden death. Likewise, the inducibility of a ventricular tachycardia or fibrillation is considered at the present time as a factor linked to sudden death and justifies the implantation of an AICD. On the other hand, a normal resting ECG only associated with a provoked ST segment elevation by class I antiarrhythmic drug (flecainide) defines a group of patients with a low risk of sudden death, and these patients do not require the implantation of an AICD.

[Postmarketing surveillance in patients with cardiac pace-makers or automatic implantable defibrillators]. / Aspects généraux et réglementaires de la matériovigilance des stimulateurs et des défibrillateurs cardiaques.

This article includes an overview of the actual French control and regulation system of the safety alerts involving pacemakers and implantable cardioverter-defibrillator and an evaluation of the general information and trends about the characteristics of the reported incidents obtained in the last years in that field. The national security agencies have the mission to collect the data on safety and efficacy of medical devices but manufacturers, physicians and patients also have a role to play. The technical appreciation of the necessity of a notification is not easy in some cases but the lack of notification of a severe incident may lead to heavy penal consequences. If doubtful cases, one should keep in mind the spirit of these safety systems: a collective insurance against the risks related to the use of medical devices. In the 10 last years, the annual advisory rate was increased. The pacemakers were recalled more frequently than implantable cardioverter-defibrillators in absolute value but less frequently in relative value (advisories per 100 person-years). This increase may be related to the growing number of device implants and expanding indications for device therapy, to the increasing sophistication of the devices and to the modifications in the regulation aspects of these problems with a closer attention of users and physicians to the several types of malfunctions.

[Conduction defects and arrhythmias in peripheral myopathies]. / Troubles conductifs et troubles du rythme dans les myopathies périphériques.

The association between peripheral myopathies and cardiac complications is well established. However, until recently, the clinical and genetic variability of these pathologies limited our ability to recognise individual risk of complications, particularly in the more rare pathologies. Advances have been made in the understanding of the progression, in the physiopathology of molecular deficits and cardiac complications of the different types of muscular dystrophy. This has partially helped to identify the risk of cardiac complications. The commonest condition, Steinert's disease, is associated with a high incidence of atrioventricular block and atrial arrhythmias. Prophylactic implantation of a dual chamber pacemaker with diagnostic functions may be envisaged when the HV interval is greater than 70 ms, on endocavitary electrophysiological investigations. In other patients, follow-up by standard ECG and/or amplified averaged ECG and Holter monitoring is essential. The natural history of Duchenne and Becker muscular dystrophies and the Emery Dreifuss dystrophy have been better described in the last few years. Recommendations have been proposed for the cardiological follow-up of these patients. Empiric recommendations of the same type have been proposed for patients with shoulder and girdle myopathies and propositions for their management have also been made, the pertinence of which is still being evaluated. Our understanding of the incidence, the type, the physiopathology and molecular biology of the various peripheral myopathies and their cardiac complications has advanced considerably in recent years. This has led to the elaboration of new recommendations for diagnostic and therapeutic strategies in these patients.

Comparative study of atrial vulnerability in patients with unexplained ischemic stroke or lone atrial paroxysmal fibrillation.

Strokes have a high prevalence, with a high rate of recurrence, and about 30-40% remain of unknown cause. Some patients might have asymptomatic paroxysmal atrial fibrillation (AF) which remains the main cause of embolic events. A latent atrial arrhythmogenic substrate may induce recurrent arrhythmias, including functional abnormalities such as nonuniform refractoriness and/or anatomic abnormalities such as atrial septum aneurysm (ASA) and patent foramen ovale (PFO). In 175 patients divided into three groups (Group I: 103 patients with unexplained ischemic stroke, Group II: 48 patients with paroxysmal AF and Group III or control group: 24 patients explored for another cause), such an atrial arrhythmogenic substrate was assessed by electrophysiological study. Groups I and II had a similar high rate of inducible atrial arrhythmias compared to control group III where no arrhythmia was induced. An induced atrial arrhythmia was observed in more than 50% of patients of Group I and in more than 70% of patients of Group II without any significant difference according to age. However, in 26 young patients of Group I who had a transesophageal echocardiography, both a high rate (46%) of ASA and/or PFO and a frequent latent atrial vulnerability (LAV) were observed, compared to older patients where an atrial septum abnormality was observed in only 21% of cases. Thus, among patients with stroke of unknown cause, a high percentage of them might have asymptomatic atrial paroxysmal arrhythmia. The predictive value of the electrophysiological study for spontaneous arrhythmias and recurrence of stroke remains to be demonstrated.

[Conduction defects as the presenting feature of sarcoidosis or observed during the course of the disease: regression with corticoid steroid therapy]. / Troubles conductifs révélant une sarcoïdose ou apparaissant au cours de son évolution: régression sous corticoïdes.

Cardiac sarcoidosis is often unrecognised because of the absence of specific clinical and electrical signs. The consequences are serious, the main risk being sudden death due to conduction defects (24 to 31% of cases) or ventricular arrhythmias. Any conduction defect without an obvious cause in a young patient should suggest a possible diagnosis of sarcoidosis. The confirmation is histological when giant cell non-caseuting epithelioid granuloma is demonstrated but myocardial biopsies are only positive in 20% of cases. Therefore, biopsy of accessible organs such as salivary glands is recommended. Diagnostic strategy consists in searching for signs of systemic sarcoidosis, and, when the diagnosis has been established, perform a complete work-up with echocardiography, dipyridamole myocardial scintigraphy, cardiac MRI and 24 hour ambulatory ECG recordings (Holter). The only proven treatment is steroid therapy with occasional spectacular observations of reversibility of arrhythmias or conduction defects.

[Arrhythmias of primary hypertrophic cardiomyopathy]. / Arythmies de la cardiomyopathie hypertrophique primitive.

Primary hypertrophic cardiomyopathy is a genetic disease causing sarcomere dysfunction. The structural and functional myocardial changes combine to produce cardiac arrhythmias related to reentry phenomena and to triggered automatic activity. The commonest arrhythmias are atrial fibrillation and ventricular arrhythmias; junctional tachycardias via the bundle of Kent are rare. Atrial fibrillation and the Wolff-Parkinson-White syndrome are more commonly associated with certain genetic mutations. Their treatment is mainly based on medication with amiodarone or on radiofrequency ablation in cases of junctional tachycardia. Ventricular arrhythmias are mainly isolated ventricular extrasystoles and non-sustained ventricular tachycardia. The prognostic significance of the latter has been subject of debate for many years but recent studies report a poor prognosis with non-sustained ventricular tachycardia especially in the young patients. Sustained ventricular tachycardia and ventricular fibrillation, though life-threatening complications of hypertrophic cardiomyopathy, are rarely documented and justify implantation of an automatic defibrillator as the risk of recurrence is high. The main objective of the cardiologist in cases of primary hypertrophic cardiomyopathy is to identify the patient at high risk of sudden death. This requires analysis of several parameters: clinical, anatomical, haemodynamic, rhythmic, functional and genetic. The presence of at least two risk factors for sudden death justifies preventive measures. The implantation of an automatic defibrillator is the most reliable form of treatment.