[The use of transesophageal echocardiography to guide the trans-septal puncture. Practical guide, tips and tricks]. / Échocardiographie transœsophagienne pour guider la ponction transseptale. Guide pratique, astuces, particularités, pièges.

Transesophageal echocardiography is very useful to guide transseptal puncture for left atrial ablation procedures. This paper is a practical guide for the ultrasonographer who seeks to meet the expectations of the electrophysiologist, but also for young EP's in order to improve their understanding of the echocardiographical views and to ameliorate the communication between the two specialists. The tips and tricks of all the steps of the exam are presented.

[A non-fatal Nerium oleander self-poisoning: case report and discussion]. / Intoxication volontaire au laurier rose ; cas clinique et revue de la littérature.

Nerium oleander is potentially lethal plants after ingestion. We report a case of poisoning by these plants. Our patient complained of nausea, vomiting, and diarrhoea. He had bradycardia during first twelve hours. He was discharge after 3 days. All parts of these plants are toxic and contain a variety of cardiac glycosides including oleandrin. In most cases, clinical management of poisoning by N. oleander involves administration of activated charcoal and supportive care. Digoxin specific Fab fragments are an effective treatment.

[Usefulness of tricuspid annular displacement (TAD) to identify right ventricular dysfunction in normotensive patients with acute pulmonary embolism]. / Intérêt du tricuspid annular displacement (TAD) dans l'évaluation de la dysfonction ventriculaire droite au cours de l'embolie pulmonaire.

BACKGROUND: Echocardiographic criteria of right ventricular dysfunction (RVD) in acute pulmonary embolism (PE) differ among published studies. Assessment of RV systolic function remains difficult because of the RV's complex shape. We aimed to evaluate RV systolic function with TAD in patients (pts) with acute PE. TAD (QLAB, Philips Medical Imaging) was based on a tissue-tracking algorithm that is ultrasound beam angle independent for automated detection of tricuspid annular displacement. DESIGN: Prospective and observational study. METHODS: All adults' pts who were diagnosed with PE from December 2008 to December 2009 at Princess Grace Hospital, Monaco were eligible for this study after exclusion of history of heart failure. We evaluated 36 consecutive pts with PE (18 male, mean age 62.7 years), which underwent echocardiography, plasma BNP titration during the first day after admission, and a second echocardiography obtained within 48 hours before discharge. RESULTS: TAD value were significantly lower in pts with abnormal RV function by echocardiogram (15.9 ± 0.3 vs. 12.7 ± 0.2 ; P = 0.026). Pts with a normal BNP (<80 pg/ml) had an elevated TAD (16.4 ± 0.2 vs. 11.2 ± 0.3 mm ; P < 0.0001). At discharge, echocardiographic data were obtained from 33 pts (mean: 8.3 ± 3.5 days). RV end diastolic diameter, RV to LV diameter, pulmonary arterial systolic pressure, mean pulmonic valve acceleration time, RV FAC, Sa and TAD were significantly improved. There was no difference between TAD among pts with echocardiographic RVD at baseline vs. pts without RVD (14.9 ± 3.7 vs. 16.1 ± 2.9 mm ; P = 0.3). Four pts who deteriorated during short-term observation had substantially lower TAD values than those with uncomplicated courses (7.7 ± 0.4mm vs. 14.6 ± 0.2 mm ; P = 0.001). In conclusion, impaired TAD was associated with decreased RV systolic function in pts with acute PE. To identify the clinical meaning of decreased TAD, larger trials with longer follow-up periods are needed.

Magnetic navigation and voltage mapping guided implantation of a pacemaker atrial lead in a previously unpaceable patient.

We report successful implantation of the atrial pacing lead in a patient in whom such operation had previously failed with the manual approach. Right atrial (RA) electro-anatomical voltage mapping was used to identify an area suitable for pacing and magnetic navigation to allow exhaustive RA exploration leading to successful RA lead screwing.

[Arrhythmia and sport]. / Arythmies du sportif.

Sports arrhythmia has gained wide attention with the mediatization of the death of famous sports stars. Sport strongly modifies the structure of the heart with the development of left ventricular hypertrophy which may be difficult to differentiate from that due to doping. Intense training modifies also the resting electrocardiogram with appearance of signs of left ventricular hypertrophy whereas resting sinus bradycardia and atrioventricular conduction disturbances usually reverts upon exertion. Accordingly, arrhythmia may develop ranging from extrasystoles to atrial fibrillation and even sudden death. Recent data suggest that if benign arrhythmia may be the result of the sole intense training and are reversible, malignant ventricular arrhythmia and sudden death mostly occur in unknown structural heart disease. Hypertrophic cardiomyopathy is amongst the most frequent post mortem diagnosis in this situation. Doping is now present in many sports and further threatens the athlete in the safe practice of sport.

[New concepts in the diagnosis and treatment of atrial flutter]. / Nouveaux concepts dans la prise en charge diagnostique et thérapeutique du flutter atrial.

Atrial flutter may now be very frequently and definitely cured in a single session of radiofrequency ablation. However, the very name of atrial flutter gives rise to a certain confusion. Clinical experience from everyday activity in ablation laboratories, especially since the introduction of new mapping techniques, has shown that this entity is in fact multiple. Flutters may be classified by their electrocardiographic appearance and/or their electrophysiological mechanism with as many prognostic as therapeutic implications. This article reviews diagnostic features of typical and atypical flutter and the different treatments which may be proposed in different clinical situations.

[Sinus-like tachycardias]. / Tachycardies d'allure sinusale.

Various tachycardias presenting with positive P waves in the standard leads are described in this article. Sinus tachycardia may occur as a normal adaptation reaction to the environment or in the setting of autonomic dysregulation. It may also be mimicked by various arrhythmias which share the earliest depolarisation in the sinus node area. The authors expose a review of these mechanisms.

[Ventricular tachycardia "in salvoes"]. / Les tachycardies ventriculaires en salves.

The term of ventricular tachycardia "in salvoes" describes electrophysiographic appearances of several consecutive ectopic ventricular beats without interposition of sinus rhythm. This is an intermediate arrhythmic state between isolated ventricular extrasystoles and sustained ventricular tachycardia. The generally accepted definition of the term "sustained" implies a duration of over 30 seconds or poor haemodynamic tolerance. Strictly speaking, the term "salvoe" has no precise definition in cardiology. In the 1996 edition of the Petit Robert French dictionary, the term is defined as the simultaneous discharge of guns or successive blasts of canons. The Delaware medical dictionary does not provide a French definition of the term "salvoe". In practice, we use the term tachycardia in salvoes in the same meaning as ventricular tachycardia. Schematically, in clinical practice, two situations may be encountered. In the first case, salvoes of VT are recorded in apparently normal hearts; they are not life-threatening and, though often nearly asymptomatic, they may pose therapeutic problems. In the second case, the arrhythmia occurs in a diseased heart, with a low ejection fraction, in which the essential problem is the vital prognosis.

[Sudden death and semi-automatic defibrillation]. / Mort subite et défibrillation semi-automatique.

While cardiac arrest in hospital poses few immediate management problems, this is not the case outside hospital. For this reason semi-automatic defibrillators are easy to handle devices designed to deliver an early electric shock in the context of usage by non-specialist people following minimum training. These devices have shown a clear improvement in survival compared to the exclusive use of a manual defibrillator by highly trained emergency services, especially in confined areas such as casinos or aircraft, or where a significant number of potential patients are concentrated, such as airports. It is now important to be able to improve public access to defibrillation by various means currently being studied, and probably by relaxing the rules which allow the use of these devices.

Atypical atrial flutters.

Typical atrial flutter is due to a counterclockwise macro-re-entry circuit localized in the right atrium with a surface ECG pattern showing predominantly negative F waves in the inferior leads and positive F waves in V1. Recently it has been proposed to classify atrial flutter on the basis of its cavo-tricuspid isthmus dependence rather than on the ECG pattern. Therefore some atrial flutters are considered typical even if the ECG does not exhibit a typical pattern. This is the case for reverse typical atrial flutter, lower loop re-entry and partial-isthmus-dependent short circuit flutter. The term atypical flutter refers to a non-isthmus dependent flutter. Usually these patients have had previous cardiac surgery with a right or left atriotomy. Flutter involving a spontaneous right atrial scar is not uncommon.

[Nodal conduction]. / La conduction nodale.

The existence of a single atrio-ventricular fascicle had been suggested in the 19th century by Wilhelm His junior. In 1906, Sunao Tawara described in details the existence of a specific muscular fascicle in charge of the atrio-ventricular conduction. Since, it has remained famous under the name of atrio-ventricular node. It is located in the apical part of the Koch triangle. It is 5 to 7 mm long and 2 to 5 mm wide and includes often an enlargement of its compact portion along the fibrous annulus to the coronary sinus ostium which seems to be associated with the development of a intra- or atrio-nodal re-entry circuit. Its action potentials are qualified as "slow response" and propagate with a speed of 0.02 to 0.05 m/sec (which is comparable to that present in the sinus node). This propagation slowness explains the PR interval on surface EKG tracings and the AH interval in intra-cardiac electrogram. When AV node cells are requested by a rapid atrial rhythm, their physiological response is made under the mode of beatings group described by Luigi Luciani and Karel Wenckebach, prior to the EKG's invention. The atrio-ventricular physiological relationship during the atrial acceleration is made according to the Luciani-Wenckebach mode and then 2/1 mode as described in the non-linear dynamics theory. The most frequent pathological of the nodal conduction are the atrio-ventricular blocks and nodal duality. They are described and commented in this article. The nodal conduction disturbances are currently accessible to different therapeutic patterns such as cardiac pacing or ablative techniques. Nonetheless the innermost mechanism are still incompletely identified and will for sure be a matter of numerous studies in the future.