Left ventricular regional function and maximal exercise capacity in aortic stenosis.

AIMS: The objective assessment of maximal exercise capacity (MEC) using peak oxygen consumption (VO2) measurement may be helpful in the management of asymptomatic aortic stenosis (AS) patients. However, the relationship between left ventricular (LV) function and MEC has been relatively unexplored. We aimed to identify which echocardiographic parameters of LV systolic function can predict MEC in asymptomatic AS. METHODS AND RESULTS: Asymptomatic patients with moderate to severe AS (n = 44, aortic valve area <1.5 cm(2), 66 ± 13 years, 75% of men) and preserved LV ejection fraction (LVEF > 50%) were prospectively referred for resting echocardiography and cardiopulmonary exercise test. LV longitudinal strain (LS) of each myocardial segment was measured by speckle tracking echocardiography (STE) from the apical (aLS) 4-, 2-, and 3-chamber views. An average value of the LS of the analysable segments was provided for each myocardial region: basal (bLS), mid (mLS), and aLS. LV circumferential and radial strains were measured from short-axis views. Peak VO2 was 20.1 ± 5.8 mL/kg/min (median 20.7 mL/kg/min; range 7.2-32.3 mL/kg/min). According to the median of peak VO2, patients with reduced MEC were significantly older (P < 0.001) and more frequently females (P = 0.05). There were significant correlations between peak VO2 and age (r = -0.44), LV end-diastolic volume (r = 0.35), LV stroke volume (r = 0.37), indexed stroke volume (r = 0.32), and E/e' ratio (r = -0.37, all P < 0.04). Parameters of AS severity and LVEF did not correlate with peak VO2 (P = NS for all). Among LV deformation parameters, bLS and mLS were significantly associated with peakVO2 (r = 0.43, P = 0.005, and r = 0.32, P = 0.04, respectively). With multivariable analysis, female gender (ß = 4.9; P = 0.008) and bLS (ß = 0.50; P = 0.03) were the only independent determinants (r(2) = 0.423) of peak VO2. CONCLUSION: In asymptomatic AS, impaired LV myocardial longitudinal function determines reduced MEC. Basal LS was the only parameter of LV regional function independently associated with MEC.

[European society of cardiology guidelines for the management of infective endocarditis (partim 1)]. / Recommandations européennes sur la prise en charge de l'endocardite infectieuse (partim 1).

Until recently, the recommendations of infective endocarditis were based on expert opinions, due to its low incidence and the absence of controlled trials. The update in 2015 of the new guidelines of the European Society of Cardiology (compared with 2009) relates to the publication of a randomised study on the surgical treatment, the innovations in imaging procedures (especially functional imaging in nuclear medicine) and the new concept of «Team Endocarditis¼ (multidisciplinary approach). Their aim is to remind the limitations of antibiotic prophylaxis and to insist on hospital hygiene measures. Future challenges will be to obtain a better understanding of the mechanisms associated with the contamination of the valve and to optimize the adaptation of the current epidemiological prophylaxis. In this first part, we will describe the preventive and diagnostic approaches of infective endocarditis.

Jusqu'à ce jour, les recommandations concernant le traitement de l'endocardite infectieuse étaient essentiellement basées sur l'opinion d'experts, à cause de sa faible incidence et de l'absence d'essais contrôlés. La mise à jour, en 2015, des recommandations de la Société Européenne de Cardiologie de 2009, est justifiée par la publication d'une première étude randomisée sur le traitement chirurgical, par les innovations concernant les procédures d'imagerie (particulièrement l'imagerie fonctionnelle en médecine nucléaire) et par le nouveau concept d'«Endocarditis Team¼ (approche multidisciplinaire). Ces directives européennes ont le mérite de rappeler les limitations de l'antibioprophylaxie et d'insister sur les mesures préventives à prodiguer. Les défis futurs seront de mieux comprendre les mécanismes associés à la contamination de l'endocarde valvulaire et de mieux adapter la prophylaxie à l'évolution épidémiologique. Dans cette première partie, nous décrivons la prophylaxie et les moyens diagnostiques de l'endocardite infectieuse.

[ACUTE CORONARY SYNDROME AND LIPID-LOWERING THERAPY. DOES THE IMPROVE-IT STUDY MAKE ANY DIFFERENCE?]. / Syndrome coronarien aigu et traitement hypolipémiant. L'étude IMPROVE-IT change-t-elle la donne?

Statins reduce both LDL cholesterol (LDL-C) levels and the risk of cardiovascular events in patients with and without cardiovascular disease. Intensive statin therapy, compared with moderate-dose statin therapy, incrementally lowers LDL-C levels and rates of cardiovascular events in patients presenting with acute coronary syndrome. Ezetimibe, by diminishing the absorption of cholesterol from the intestine, additionally reduces LDL-C when added to statins. In this article, we discuss the potential benefits of the combination of simvastatin and ezetimibe for the long-term management of patients with acute coronary syndrome through an analysis of the IMPROVE-IT results (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial). This randomised double blind trial included 18,144 patients with a LDL-C of 50 to 100 (with statin) or 125 (without statin) mg/dl and had a median follow-up of 6 years. The objective of the study was to test the efficacy of simvastatin 40 mg versus simvastatin 40 mg and 10 mg ezetimibe. The primary endpoint included cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina and coronary revascularization. The addition of ezetimibe to simvastatin resulted in an incremental lowering of LDL-C (reached value 53.2 versus 69.9 mg/dl, p < 0.001) and a further improvement of the patient prognosis (relative reduction of primary endpoint: -6.4%, p = 0.016). In addition, the combined therapy showed no significant adverse effects, particularly regarding the risk of cancers, which confirms the safety of ezetimibe. In acute coronary syndrome, the prescription of ezetimibe should be considered (class HA, level of evidence B) in patients with a LDL-C a 70 mg/dl despite maximally tolerated dose of statin.

Impact of global hemodynamic load on exercise capacity in aortic stenosis.

BACKGROUND: The determinants of maximal exercise capacity (MEC) in aortic stenosis (AS) are, in large part, unknown. We hypothesized that the left ventricular (LV) global hemodynamic load--as assessed by the valvulo-arterial impedance (Zva)--is one of the main determinants of MEC and we sought to evaluate the factors associated with reduced MEC in AS. METHOD AND RESULTS: Asymptomatic patients with moderate or severe AS (n=62, aortic valve area <1.5 cm(2), 65 ± 13 years, 68% men) and preserved LV systolic function (ejection fraction>50%) were prospectively referred for comprehensive resting echocardiography and cardiopulmonary exercise test. Absolute peak VO2 was 19.5 ± 5.7 mL/kg/min (median 19.6 mL/kg/min; range 7.2-33.1 mL/kg/min). There were significant correlations between peak VO2 and: age, body mass index, LV stroke volumes, cardiac output, mean flow rate, mitral annulus s' and e' wave velocities, E/e' ratio and left atrial diameter (all p<0.05). Indexed mean flow rate and Zva were the strongest univariable echocardiographic determinants of peak VO2 (r=0.44, p<0.001 and r=-0.39, p=0.002, respectively). In addition, patients with reduced MEC (peak VO2

[Clinical case of the month. Cardiac complications of acromegaly: a rare cause of dilated cardiomyopathy]. / Le cas clinique du mois. Complications cardiaques de l'acromégalie: cas rare de cardiopathie dilatée.

Acromegaly is a disease characterized by chronic growth hormone hypersecretion. Cardiovascular complications represent the main cause of death. We present here a rare case of dilated cardiomyopathy whose diagnosis revealed an acromegaly. This will provide the opportunity to review an uncommon disease and its recently reassessed prevalence.

[Inadvertent implantation of a defibrillation lead in the left ventricle through a patent foramen ovale]. / Le cas clinique du mois: Implantation fortuite d'une sonde de défibrillation dans le ventricule gauche au travers d'un foramen ovale perméable.

Inadvertent insertion of a defibrillation lead in the left ventricle is a rare complication generally underdiagnosed after device implantation. Management is not strictly codified due to the small number of observed cases. We report the case of a 78 year-old man in whom the diagnosis has been performed lately during an echocardiography.

[How I explore: ventricular arrhythmias in athletes]. / Une arythmie ventriculaire chez le sportif.

Documented ventricular tachyarrhythmias or related symptoms need meticulous cardiac investigations. The mechanism of ventricular arrhythmia must be defined. The prognosis is related to underlying cardiac electrical or structural disorders. In the absence of cardiovascular abnormalities, the prognosis is good. No disqualification to competitive activity is required in most cases. Assessment of the risk of sudden death remains a continuing challenge in athletes. This article reviews the diagnostic and therapeutic approaches of ventricular arrhythmias encountered in trained athletes.

[The long QT syndrome]. / Le syndrome du QT long congénital.

The congenital long QT syndrome (LQTS) is a hereditary cardiac disease characterized by a prolongation of the QT interval > 440 ms at rest ECG associated with a high risk of ventricular arrhythmias (torsade de pointe). Clinical manifestations are syncope and sudden cardiac death. The implicated genes encode cardiac ion channel subunits or proteins involved in modulating ionic currents. The diagnosis of LQTS can be complex in borderline cases. Etiology, pathogenesis, diagnosis and treatment are discussed.

[Treatment adherence to guidelines for the management of chronic heart failure]. / Adhésion aux recommandations pour la prise en charge de l'insuffisance cardiaque chronique.

Chronic heart failure is a growing public health problem with a bad prognosis. Despite the seriousness of this syndrome and the well defined therapeutic approach, adherence to guidelines remains poor. After briefly recalling the main points of these guidelines, we present statistical data regarding therapeutic care of these patients. We then present factors influencing prescription or non prescription of heart failure drugs and emphasize the importance of a team management programme and patients pathways.

[Clinical inertia and treatment adherence in the management of chronic valvular heart diseases]. / Inertie clinique et observance thérapeutique dans les valvulopathies chroniques du coeur gauche.

Valvular heart diseases are of increasing importance among the general adult population. When compared with other heart diseases, there are few trials in the field of valvular heart disease and randomized clinical trials are particularly scarce. Two sets of guidelines exist: one in the USA and the other in Europe. However, they are not always consistent due to the lack of randomized data and it appears that, frequently, there is a gap between the existing guidelines and their effective application.

[Adherence to the rules for antithrombotic treatment in atrial fibrillation]. / Adhésion aux règles du traitement anti-thrombotique dans la fibrillation auriculaire.

Adherence to the rules for antithrombotic ment in atrial fibrillation patients significantly reduces the risk of stroke. We review the criteria for the use of anti-vitamin K as well as its daily management in patients with atrial fibrillation.

[Tachycardia-related cardiomyopathy: a case report]. / Cardiomyopathie rythmique.

Tachycardia-mediated cardiomyopathy is a form of dilated cardiomyopathy and heart failure induced by a persistent/chronic supraventricular or ventricular tachyarythmia. The incidence and the patho-physiology remain unspecified. Sometimes related to a previous cardiomyopathy, the diagnosis is always retrospective, but important because of the clinical and the significant haemodynamic improvement following the control of heart rate.

[Risk stratification in hypertrophic cardiomyopathy]. / Stratification du risque dans la cardiomyopathie hypertrophique.

Hypertrophic cardiomyopathy is of genetic origin, characterized by asymmetric left ventricular hypertrophy and variable clinical presentation. The physiopathology includes diastolic dysfunction and, in one third of the patients, dynamic left ventricular outflow tract obstruction. Patients are at increased risk of sudden death. Risk stratification in the individual patient is an essential component of management. This article describes the clinical presentation of a patient and his mother and summarizes essential features of the disease and the current recommendations for the prevention of sudden cardiac death.

[Antiplatelet therapy: should it be withdrawn before any invasive procedure?]. / Antiagrégants: doit-on les arrêter avant un acte invasif?

Antiplatelet therapy is the leading therapy for the primary and secondary prevention for the atherosclerotic arterial disease. The practical question of withdraw alavoiding or continuation of oral antiplatelet agents accurs currently before any invasive procedure. It is important to compare the relative thrombotic vs hemorrhagic risk. For most interventions, it is recommended to continue antiplatelet therapy. It is particularly important in patients who benefited from drug-eluting stents where the thrombotic risk is major.

[Update in the management of left valvular disease]. / Nouveautés dans la prise en charge des valvulopathies du coeur gauche.

In the last years, the management of left valvular disease has considerably evolved. The American guidelines of 1998 were recently reviewed. Since this year, we have European guidelines which are different in some points. The place of exercise testing in risk stratification of asymptomatic valvular disease is increasing and helps to make earlier decision regarding the need for surgery.

[Secondary prevention after a myocardial infarction]. / Prévention secondaire après un infarctus du myocarde.

Patients after a myocardial infarction are at increased risk of adverse cardiovascular outcomes. They require aggressive secondary preventive measures to control cardiovascular risk factors, and prescription of some pharmacological agents. Compelling data derived from randomized controlled trials have shown the benefits of aspirin (or clopidogrel), statins, beta-blockers and angiotensin-converting enzyme inhibitors, in preventing recurrent events and improving survival. In some cases oral anticoagulants or fibrates may be necessary. Other agents as antioxidant vitamins, folate and B vitamins are disappointing. Lifestyle and dietary modifications can also have an important beneficial effect on mortality rates and should never be neglected.