Association between COVID-19 Diagnosis and Coronary Artery Thrombosis: A Narrative Review.

Coronavirus disease 2019 is characterized by its severe respiratory effects. Data early on indicated an increased risk of mortality in patients with cardiovascular comorbidities. Early reports highlighted the multisystem inflammatory syndrome, cytokine storm, and thromboembolic events as part of the disease processes. The aim of this review is to assess the association between COVID-19 and its thrombotic complications, specifically related to the cardiovascular system. The role of neutrophil extracellular traps (NETs) is explored in the pathogenesis of the disease. The structure and anatomy of the virus are pivotal to its virulence in comparison to other α and ß Coronaviridae (HCoV-229E, HCoV-OC43, HCoV-229E, HCoV-NL63, HCoV-OC43, and HCoV-HKU1). In particular, the host interaction and response may explain the variability of severity in patients. Angio tensin-converting enzyme 2 (ACE2) activation may be implicated in the cardiovascular and throm bogenic potential of the disease. The virus may also have direct effects on the endothelial lining affecting hemostasis and resulting in thrombosis through several mechanisms. Dipyridamole may have a therapeutic benefit in NET suppression. Therapeutic avenues should be concentrated on the different pathophysiological steps involving the virus and the host.

A 5-year clinical follow-up after duty-cycled phased RF ablation of paroxysmal atrial fibrillation.

PURPOSE: Catheter radiofrequency ablation (RFA) is an effective treatment for symptomatic paroxysmal atrial fibrillation (AF). It has been demonstrated that the multielectrode pulmonary vein ablation catheter (PVAC) has favourable outcomes at 6-12 months post-ablation, but there are only few studies with a long-term follow-up. METHODS: We retrospectively reviewed 77 consecutive PVAC procedures in our centre, from November 2007 to December 2012. RFA was attempted in patients with symptomatic paroxysmal AF (mean age 58.7 ± 9.8 years, 50 men (64.9 %). The ablation strategy consisted of circumferential pulmonary vein isolation (CPVI) with the PVAC system. A questionnaire was used over the follow-up period to assess the efficacy of AF ablation. Success was defined as freedom from AF/atrial flutter or atrial arrhythmia for a period ranging from 3 to 12 months or more. RESULTS: Seventy-seven patients were included with paroxysmal AF. The mean duration of the procedure was 99.6 ± 26 min and fluoroscopy time 19.4 ± 6.8 min. Time of RFA was 22.4 ± 5.8 min. Acute complication rate was 10.4 % (the most frequent was vascular injury for 6 patients 7.8 %, 1 patient presented sepsis (1.3 %), 1 patient presented transient ischemic stroke). After a single procedure at a mean FU of 55 ± 11 months, 54/77 (70.1 %) patients were free of symptomatic AF. CONCLUSIONS: These long-term results suggest that PVAC is an efficient system for CPVI of symptomatic paroxysmal AF.

Prevalence, clinical characteristics and outcomes of high-risk patients treated for severe aortic stenosis prior to and after transcatheter aortic valve implantation availability.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) has emerged as an effective treatment for high-risk patients with severe aortic stenosis (AS). The aim of our study was to compare the prevalence, characteristics and outcomes of high-risk patients treated prior to and after the availability of TAVI in our high-volume surgical institution. METHODS: Among 879 consecutive patients treated 2 years before ('pre-TAVI era') and after ('modern era') the availability of TAVI in our institution, 83 patients were at high risk [defined by logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) >20%]. RESULTS: Among all patients treated for severe AS, the prevalence of high-risk patients was higher in the modern era (12.7 vs 4.9%, P < 0.0001). In the modern era, high-risk patients were treated by TAVI in 89% of cases. Despite similar logistic EuroSCORE (34.9 vs 34%, P = 0.96), the clinical characteristics of these patients have evolved: high-risk patients in the modern era were older (85.3 ± 5.9 vs 78.5 ± 6.5 years, P = 0.0005) and presented more frequently with New York Heart Association class III-IV (92.3 vs 61.1%, P = 0.003), while high-risk patients treated by surgical aortic valve replacement in the pre-TAVI era presented more frequently with a critical preoperative status (33.3 vs 7.7%, P = 0.01), lower left ventricular ejection fraction (41 ± 14 vs 49 ± 15%, P = 0.05) and a history of recent myocardial infarction (27.8 vs 6.1%, P = 0.02). The overall 1-year survival was not different for high-risk patients treated in the pre-TAVI era or in the modern era (61 ± 11 vs 68 ± 6%, P = 0.52). CONCLUSIONS: The availability of TAVI has increased the prevalence of high-risk patients treated for severe AS and changed the clinical features of this kind of patients who were rarely surgically treated before. The 1-year survival was similar between pre-TAVI and modern eras.

Relationship between New York Heart Association class change and ventricular tachyarrhythmia occurrence in patients treated with cardiac resynchronization plus defibrillator.

AIMS: In patients with advanced heart failure (HF) and prolonged QRS interval, cardiac resynchronization therapy (CRT) reduces symptoms and risk of death. The added benefit of an implantable cardioverter defibrillator (ICD) remains questionable in some patients. METHODS AND RESULTS: In 332 HF patients treated with CRT-D (CRT with ICD) [65 +/- 10 years, 86% men, 23% New York Heart Association (NYHA) class II, 65% class III, and 11% class IV, 70% primary prevention, 55% ischaemic cardiomyopathy, left ventricular ejection fraction 25 +/- 7.5%, and QRS width 167 +/- 32 ms], we evaluated the relationship between functional status change, death at 6-month follow-up (FU), and the occurrence of ventricular tachyarrhythmia/ventricular fibrillation (VT/VF). A total of 68 patients (20.5%) experienced 1266 spontaneous episodes of VT/VF during FU. There was no difference in baseline characteristics between patients with or without VT/VF, except for ICD indication (primary or secondary prevention). Improvement in NYHA class was significantly associated with a decreased occurrence of VT/VF (P = 0.004). Sixteen patients who died had significantly more often VT/VF than the survivors (50 vs. 19%, P = 0.007). CONCLUSION: Within the initial 6-month post-CRT therapy, 20% of patients received an appropriate ICD therapy. Patients improving on NYHA class (responders to CRT) have less VT/VF episodes than non-responders. Discriminant criteria for CRT response are awaited to optimize the choice of the device (CRT alone, defibrillator alone, or CRT-D).

Abnormalities of ventricular repolarization in mitral valve prolapse.

OBJECTIVES: Mitral valve prolapse (MVP) is associated with arrhythmias and sudden death. Some studies suggest that abnormalities of the autonomic nervous system (ANS) may contribute to these arrhythmias. In a family investigation with genetic analysis of patients carrying a MVP, we performed a Holter study to define the autonomic profile of MVP. METHODS AND RESULTS: A 24-hour digitized 3-lead Holter ECG was recorded in 30 patients with MVP and in two control groups, a group of 30 healthy relatives and a group of 31 healthy volunteers. We studied especially heart rate variability (HRV) and QT dynamicity. The slope of the relationship between ventricular repolarization and heart rate was studied separately during day and night. There was no difference in HRV (SDNN, rMSSD) among the three groups. On the contrary, QT interval duration was increased in patients with MVP as compared to healthy relatives (QT end: 409+/-52 ms vs 372+/-23 ms, P<0.05; QT apex: 319+/-42 ms vs 286+/-23 ms, P<0.01) and to healthy volunteers (QT end: 409+/-52 ms vs 376+/-25 ms, P=0.004; QT apex: 319+/-42 ms vs 289+/-23 ms, P<0.01). Nocturnal ventricular repolarization rate dependence was increased in MVP as compared to healthy relatives (0.16+/-0.06 vs 0.13+/-0.04, P<0.05) and to healthy volunteers (0.16+/-0.06 vs 0.11+/-0.06, P<0.001) whereas the 24-hour and diurnal QT-R-R slope was not disturbed. CONCLUSION: In MVP, QT is increased and the circadian modulation of QT end/RR slope is disturbed with an increased nocturnal rate dependence. These abnormalities of ventricular repolarization might explain the risk of arrhythmic events in MVP.

Cost of care distribution in atrial fibrillation patients: the COCAF study.

BACKGROUND: Atrial fibrillation (AF) currently represents a major economic burden for society. Very few studies have been performed to evaluate the cost of care for AF patients. This study is a large prospective survey designed to analyze the different cost drivers in the treatment of these patients. This survey, named Cost of Care in Atrial Fibrillation (COCAF), evaluated the cost of care for patients with AF treated by cardiologists in general office practice. METHODS: A group of 671 patients was recruited by 82 cardiologists distributed in all regions of France. The mean age of the patients was 69 years, and 64% were male. The mean follow-up was 329 +/- 120 days. The costs of care were analyzed from the health care payer and the societal perspectives. RESULTS: During the follow-up period, 21 patients (3.13%) died and 210 (31.3%) patients were hospitalized. The number of hospitalizations and deaths was significantly higher in the group of persistent or permanent AF (PEAF) patients, as compared to paroxysmal AF (PAAF) patients. Hospitalizations were much more frequent in the PEAF group (127) than in the PAAF group (83, P <.05). Deaths were also much more frequent in the PEAF group (17) as compared to the PAAF group (4, P <.001). From the societal perspective, the first cost driver was hospitalizations (52%), followed by drugs (23%), consultations (9%), further investigations (8%), loss of work (6%), and paramedical procedures (2%). In multivariate analysis the following parameters were significantly associated with higher costs: heart failure (P <.04), coronary artery disease (P <.001), use of class III antiarrhythmic drugs (P <.002), hypertension (P <.002) and metabolic disease (P <.001). CONCLUSIONS: This prospective survey shows that hospitalizations represent the major cost driver in the treatment of AF patients. Outpatient care programs must be proposed to AF patients in order to avoid readmissions and to reduce the cost of treatment.

Heart rate variability before ventricular arrhythmias in patients with coronary artery disease and an implantable cardioverter defibrillator.

BACKGROUND: Changes in autonomic regulation of the heart may be responsible for the occurrence of arrhythmias. Although a decrease in 24-hour heart rate variability is a strong predictor of subsequent arrhythmias in patients with heart disease, many questions remain unanswered concerning changes in heart rate and heart rate variability in the minutes or hours preceding an arrhythmia. The aim of our study was to analyze changes in heart rate and heart rate variability occurring during the 90 minutes preceding an arrhythmia, in patients with coronary heart disease and an implantable defibrillator. MATERIALS AND METHODS: Thirty-eight patients, with a total of 93 episodes of ventricular arrhythmia, were included in the study. Heart rate and heart rate variability were measured in three 30-minute and five 2-minute periods preceding the arrhythmia. Heart rate variability was assessed using measurements of Poincaré plots. RESULTS: The results show a gradual increase in heart rate before the arrhythmia, from 73+/-13/min, to 75+/-14/min, and finally 78+/-15/min in the 90 minutes preceding the arrhythmia (P<0.05). CONCLUSION: Measurements of Poincaré plots showed a significant increase in their length and no significant change in their width. These results suggest that sympathetic activation is the predominant change in autonomic nervous system before a ventricular arrhythmia in patients with coronary heart disease. This change may occur as early as one hour and a half before the arrhythmia.