[New perspectives in the diagnosis and treatment of heart failure with preserved ejection fraction (HFpEF)]. / Avancées dans le diagnostic et traitement de l'insuffisance cardiaque à fraction d'éjection préservée.

Heart failure with preserved ejection fraction (HFpEF), defined as ≥50 %, affects 1 to 3 % of the population and represents a diagnostic challenge. Clinical scores have been developed to facilitate the diagnosis of affected patients, who can now benefit from new treatments. Recent studies have shown a reduction in cardiovascular morbidity and mortality with sodium-glucose cotransporter-2 (SGLT-2) inhibitors in this population. Other promising drugs, currently in the study phase, could potentially change the management approach in the near future. Finally, controlling symptoms, signs of congestion and the frequently encountered comorbidities in this population remain crucial.

L'insuffisance cardiaque à fraction d'éjection préservée (HFpEF), soit ≥ 50 %, touche 1 à 3 % de la population et représente un défi diagnostique. Des scores cliniques ont été développés pour faciliter l'identification des patients concernés qui peuvent désormais bénéficier de nouveaux traitements. Des études récentes ont en effet montré une diminution de la morbimortalité cardiovasculaire grâce aux inhibiteurs du cotransporteur sodium-glucose de type 2 (iSGLT2) dans cette population. D'autres médicaments prometteurs actuellement en phase d'étude pourraient aussi changer la prise en charge dans un futur proche. Enfin, le contrôle des symptômes et signes de congestion ainsi que le traitement des comorbidités fréquemment rencontrées dans cette population restent essentiels.

[Bradyarrythmias in acute coronary syndromes]. / Bradyarythmies dans le syndrome coronarien aigu.

In up to 30-40% of the cases acute coronary syndrome (ACS) is complicated by cardiac arrhythmias. The latter can be benign or malignant and mainly occur during the first 24 hours after myocardial infarction. Ischemia time being the key factor, arrythmias decreased dramatically since the implementation of accelerated reperfusion strategies. Bradyarrhythmias are often benign and self-limiting and are less frequent than tachyarrhythmias but can sometimes require specific treatment. The objective of this article is to provide an update on bradycardia and conduction system disorders occurring during ACS and their management.

Le syndrome coronarien aigu (SCA) est compliqué d'arythmies cardiaques jusque dans 30 à 40 % des cas. Celles-ci peuvent être bénignes ou malignes et surviennent principalement durant les premières 24 heures après l'infarctus du myocarde (IDM). Le temps d'ischémie étant le facteur clé, elles sont en baisse depuis la mise en place de stratégies de reperfusion accélérées. Les bradyarythmies, souvent bénignes et spontanément résolutives, sont moins fréquentes que les tachyarythmies mais peuvent parfois nécessiter une prise en charge spécifique. L'objectif de cet article est une mise à jour sur les bradycardies et troubles de la conduction survenant lors d'un SCA ainsi que leurs prises en charge.

Current of injury amplitude during left bundle branch area pacing implantation: impact of filter settings, ventricular pacing, and lead type.

AIMS: Monitoring current of injury (COI) during left bundle branch area pacing (LBBAP) implantation is useful to evaluate lead depth. Technical aspects for recording COI amplitude have not been well studied. Our aims were to evaluate the impact of high-pass filter settings on electrogram recordings during LBBAP implantation. METHODS AND RESULTS: Consecutive patients with successful LBBAP implantation had unipolar recordings of COI at final lead position at different high-pass filter settings (0.01-1 Hz) from the tip electrode during sensing and pacing, and from the ring electrode during sensing. Duration of saturation-induced signal loss was also measured at each filter setting. COI amplitudes were compared between lumenless and stylet-driven leads. A total of 156 patients (96 males, aged 81.4 ± 9.6 years) were included. Higher filter settings led to significantly lower COI amplitudes. In 50 patients with COI amplitude < 10 mV, the magnitude of the drop was on average 1-1.5 mV (and up to 4 mV) between 0.05 and 0.5 Hz, meaning that cut-offs may not be used interchangeably. Saturation-induced signal loss was on average 10 s at 0.05 Hz and only 2 s with 0.5 Hz. When pacing was interrupted, the sensed COI amplitude varied (either higher or lower) by up to 4 mV, implying that it is advisable to periodically interrupt pacing to evaluate the sensed COI when reaching levels of ∼10 mV. Lead type did not impact COI amplitude. CONCLUSION: High-pass filters have a significant impact on electrogram characteristics at LBBAP implantation, with the 0.5 Hz settings having the most favourable profile.

Procedural outcome and follow-up of stylet-driven leads compared with lumenless leads for left bundle branch area pacing.

AIMS: Left bundle branch area pacing (LBBAP) is most often delivered using lumenless leads (LLLs), but may also be performed using stylet-driven leads (SDLs). There are limited reports on the comparison of these tools, mainly limited to reports describing initial operator experience or without detailed procedural data. Our aim was to perform an in-depth comparison of SDLs and LLLs for LBBAP at implantation and follow-up in a larger cohort of patients with experience that extends beyond that of the initial learning curve. METHODS AND RESULTS: A total of 306 consecutive patients (age 77 ± 11 years, 183 males) undergoing LBBAP implantation at a single centre were prospectively included. The population was split into two groups of 153 patients based on the initial use of an SDL (from 4 manufacturers) or an LLL. After having discounted the initial learning curve of 50 patients, there was no difference in the success rate between the initial use of lead type (96.0% with SDL vs. 94.3% with LLL, P = 0.56). There were no significant differences in success between lead models. Electrocardiogram and electrical parameters were comparable between the groups. Post-operative macro-dislodgement occurred in 4.3% of patients (essentially within the first day following implantation) and presumed micro-dislodgement with loss of conduction system capture or rise in threshold (occurring mostly during the first month) was observed in 4.7% of patients, without differences between groups. CONCLUSION: Left bundle branch area pacing may be safely and effectively performed using either LLLs or SDLs, which provides implanters with alternatives for delivering this therapy.

[Cardiac tumors in clinical practice]. / Les tumeurs cardiaques.

Cardiac tumors are rare in clinical practice but remain an essential part of the fast-growing field of cardio-oncology. They can be detected incidentally and consist of primary tumors (benign or malignant) and of the more prevalent secondary tumors (metastasis). They form a heterogeneous group of pathologies presenting with a wide panel of clinical symptoms according to their location and size. Multimodality cardiac imaging (echocardiography, CT, MRI and PET), in association with clinical and epidemiological factors, plays a key role in the diagnosis of cardiac tumors and a biopsy is therefore not systematically required. Treatment strategies for cardiac tumors vary depending on the malignancy and class of the tumor, but also consider associated symptoms, hemodynamic impact and embolic risk.

Les tumeurs cardiaques sont des pathologies rares mais elles ­appartiennent à un domaine en plein essor de la cardio-oncologie. Souvent découvertes fortuitement, elles comprennent les ­tumeurs cardiaques primaires (bénignes ou malignes) et, plus fréquemment, secondaires (métastases). Elles constituent un ­ensemble très hétérogène de pathologies, dont les manifestations cliniques varient en fonction de la taille et de la localisation. Le diagnostic repose sur une approche clinique, épidémiologique et plusieurs modalités d'imagerie (échocardiographie, CT, IRM et PET-CT), sans nécessité systématique de biopsie. La stratégie de traitement d'une tumeur cardiaque dépend de la symptomatologie du patient, du risque embolique ou hémodynamique lié à la masse, ainsi que de sa malignité.

Coronavirus disease 2019-associated coronary endotheliitis and thrombotic microangiopathy causing cardiogenic shock: a case report.

Background: Coronavirus disease 2019 (COVID-19) primarily affects the respiratory tract but serious cardiovascular complications have been reported. Up to one-third of patients admitted to the intensive care unit may develop an acute myocardial injury, characterized by cardiac troponin elevation. However, the pathology underlying COVID-19-associated myocardial injury has rarely been reported. Case summary: Three days after being diagnosed for a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, a 52-year-old woman without a notable past medical history developed cardiogenic shock with severely reduced left ventricular ejection fraction (LVEF) at 25%. Coronary angiography was normal. Endomyocardial biopsy demonstrated coronary endotheliitis with multiple microvascular thromboses but no lymphocytic infiltrate and a negative polymerase chain reaction for SARS-CoV-2. The patient was implanted with a short-term LV assist device (Impella CP®, Abiomed, Aachen, Germany) and treated with therapeutic anticoagulation. She suffered from concomitant respiratory failure that required 14 days of orotracheal intubation, 10 days of dexamethasone, and broad-spectrum antibiotics. Clinical outcome was favourable with weaning of the Impella device after 6 days and full recovery of LVEF (65%) at 30 days. Cardiac magnetic resonance performed at Day 30 showed no evidence of myocarditis or scars and confirmed the normalization of LVEF. Discussion: This case highlights how COVID-19-associated coronary endotheliitis and thrombotic microangiopathy, in the absence of myocarditis, may induce transient severe LV dysfunction and cardiogenic shock.

[Myocarditis in 2020]. / La myocardite en 2020.

Myocarditis is an inflammatory disease of the myocardium caused by various etiologies with a dominance of viral infections and potential post-infectious autoimmunity. The clinical presentation ranges from chest pain to severe complications including cardiogenic shock, ventricular arrhythmias, and progression to dilated cardiomyopathy. The diagnostic approach is challenging and includes several investigations, such as an ECG, an echocardiography, troponin testing and the exclusion of coronary artery disease. Although endomyocardial biopsy remains the gold standard, cardiovascular magnetic resonance is now the most valuable tool to accurately characterize myocardial tissue inflammation. The management is mainly symptomatic and consists in early detection and treatment of complications including heart failure and arrhythmias.

La myocardite est une inflammation du muscle cardiaque dont les étiologies sont variées, avec une prédominance d'atteinte infectieuse virale et d'une autoimmunité postinfectieuse. Le spectre clinique varie de la douleur thoracique aux complications comme le choc cardiogénique, les arythmies malignes et la cardiomyopathie dilatée. La démarche diagnostique est un défi pour le clinicien et comprend un ECG, un bilan biologique, une échocardiographie, ainsi que l'exclusion d'une maladie coronarienne. La biopsie myocardique reste le gold standard, mais l'imagerie par résonance magnétique est actuellement l'examen de référence pour caractériser avec précision le tissu myocardique inflammatoire. La prise en charge est essentiellement symptomatique et consiste à dépister et traiter précocement les complications comme l'insuffisance cardiaque et les arythmies.

Leadless pacing using the transcatheter pacing system (Micra TPS) in the real world: initial Swiss experience from the Romandie region.

AIMS: Leadless pacemakers are implanted in Switzerland since June 2015. Large worldwide registries have shown high implant success, low complication rates, and good electrical parameters up to 12 months' follow-up. However, data are scarce outside the investigational setting. The purpose of this study is to assess the real-world experience regarding clinical safety and efficacy of Micra TPS (transcatheter pacing system) leadless pacemakers. METHODS AND RESULTS: Retrospective observational, multi-centre study designed to assess initial safety and efficacy of the Micra TPS in the Swiss Romande region. A total of 92 patients were included from four different centres with an implantation success rate of 97.8% (90 of 92). Thresholds were overall low at implantation (median 0.38 V/0.24 ms, ranging from 0.13 to 2.88 V/0.24 ms) and remained stable over 1-year follow-up. The perioperative serious adverse event rate was 6.5% in six patients which lead to prolonged hospitalization in five patients and death in one patient. In addition, three further major events (3.3%) occurred during an average follow-up of 1 year, requiring implantation of a standard transvenous pacemaker in two patients, and surgical explantation of the Micra TPS in one patient due to intractable ventricular tachycardia. CONCLUSION: Leadless pacemakers are a valuable adjunct for treating selected patients requiring single-chamber pacing. However, in this initial experience, major complication rates were high (9.8%). The implant procedure requires proper training and should be performed in an adequate setting.