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L'accident vasculaire cérébral cryptogénique est une définition ancienne pour classer un événement neurologique ischémique sans cause bien identifiée. La forte probabilité d'un mécanisme thromboembolique pour expliquer certains infarctus cérébraux cryptogéniques, a conduit à une nouvelle définition : l'accident vasculaire cérébral embolique de source indéterminée. Ce sous-groupe des accidents vasculaires cérébraux cryptogéniques reste hétérogène en raison des nombreuses sources thromboemboliques potentielles et pouvant être associées. La fibrillation auriculaire occulte est sans doute moins souvent en cause que prévue initialement, au contraire de l'athérome extracrânien et intracrânien. Le cardiologue doit s'impliquer dans la démarche diagnostique en aidant le neurologue à identifier la cause la plus probable. Des recherches complémentaires sont nécessaires pour sélectionner les populations qui pourraient bénéficier d'un traitement préventif individualisé plus efficace. Cryptogenic stroke is an old definition that designates an ischemic stroke with no identifiable cause. The term of the embolic stroke of undetermined source was then introduced to identify non-lacunar strokes in whom thromboembolism was the likely mechanism. This subgroup of cryptogenic strokes remains heterogeneous with many potential and possibly associated embolic causes. Covert atrial fibrillation is probably less often involved than initially expected, in contrast to intracranial and extracranial atherosclerosis. The cardiologist should be involved in the search of underlying causes of ischemic stroke by helping the neurologist to identify the most likely diagnosis. Further research is necessary to select populations that may benefit from more effective and individualized treatment. [ABSTRACT FROM AUTHOR]

Le scanner coronaire est indiqué dans le bilan de douleurs thoraciques chez tous les patients avec une préférence pour ceux ayant un risque faible à intermédiaire de coronaropathie. Les études récentes ont complété cette indication en démontrant sa fiabilité dans le bilan de douleurs thoraciques chez les patients à haut risque de coronaropathie, notamment dans le syndrome coronaire aigu (SCA) sans élévation du segment ST. Il apparaît également intéressant et prometteur pour le dépistage cardiovasculaire en prévention primaire chez un patient porteur de facteurs de risque cardiovasculaire, permettant ainsi d'ajuster la stratégie préventive et notamment le traitement par statine, ainsi que pour le suivi du coronarien stenté ou ponté. Le score calcique a démontré être un marqueur prédictif du risque de mortalité, cardiovasculaire et totale, indépendant des autres facteurs de risque connus et son usage est recommandé dans la stratification du risque cardiovasculaire. Cependant, son interprétation reste délicate de même que le changement dans la prise en charge que le résultat implique pour le patient. Un score calcique supérieur à zéro marque la présence d'une athérosclérose coronaire et doit faire discuter un traitement hypolipémiant. Dans le cadre du bilan pré-TAVI, le scanner cardiaque est devenu le gold standard pour la mesure de l'anneau aortique et le choix de la prothèse à implanter, ainsi que pour toutes les mesures réglementaires avant la procédure. Enfin, le bilan pré-ablation de fibrillation auriculaire comprend désormais un scanner cardiaque permettant d'éliminer un thrombus de l'oreillette gauche ou de l'auricule gauche, de rechercher un retour veineux pulmonaire anormal et de fournir un support 3-D pour la navigation lors de la procédure rythmologique interventionnelle d'ablation. Cardiac CT-scan is recommended for sorting patients presenting with stable or acute chest pain with low to intermediate risk of coronary artery disease (CAD). Recent studies have shown its reliability for diagnosing CAD in high-risk patients, notably those with acute coronary syndrome (ACS) without ST-elevation. Coronary CT-scan also represents a great opportunity for the screening of atherosclerosis in patients at risk and allows a better prevention of coronary artery disease by introduction of preventive treatments in patients with abnormal coronary CT-scan, especially statins. It is useful for the follow-up of patients who underwent a coronary arteries revascularization with either stents or bypasses. Coronary arteries calcium scoring appears to be an independent predictive factor of cardiovascular and total mortality and its use is recommended for stratifying the cardiovascular risk. However, its interpretation remains unobvious and the patient management is poorly improved by the results. Anyway, if the score is above zero, atherosclerosis is present and therefore a lipid lowering treatment should be discussed. Cardiac CT-scan has become the Gold Standard exam before an aortic valve replacement, for the measurement of the aortic root notably, allowing the best prothesis selection. Before atrial fibrillation ablation procedure by pulmonary vein isolation, the cardiac CT-scan allows a 3-D visualization of the two atria, especially the left atrium, and rules out any suspicion of cardiac thrombus. It allows the research of an anomalous pulmonary venous connection. The 3-D support will also enable the operator to navigate in the heart during the ablation procedure. [ABSTRACT FROM AUTHOR]

L'évaluation fonctionnelle des sténoses coronaires par FFR fractional flow reserve (FFR) est une technique d'application quotidienne dans les salles de cathétérisme ; elle est réputée fiable, reproductible et très sure avec un très faible taux d'effets indésirables ; nous rapportons l'observation d'un patient de 68 ans sans antécédents d'arythmie chez lequel une injection intracoronaire d'adénosine pendant une mesure de FFR pour évaluation d'une sténose intermédiaire de la coronaire droite a immédiatement induit un passage en fibrillation auriculaire nécessitant une hospitalisation de 24 h pour cardioversion pharmacologique. Fractional flow reserve (FFR) measurement for functional evaluation of haemodynamic relevance of coronary artery stenoses is a well established and straightforward method applied on daily basis in cardiac catheterization laboratory; it is known to be reliable, reproducible and secure associated with a low rate of adverse events. We report the case of a 68-year-old man with no history of arrhythmias in whom intracoronary injection of adenosine for FFR assessment immediately induced atrial fibrillation mandating hospitalization for pharmacological cardioversion. [ABSTRACT FROM AUTHOR]

Atrial fibrillation is associated with increased risk of morbidity and mortality. There's limited data on the outcomes of atrial fibrillation patients in Africa. We aimed at evaluating the clinical outcomes and their associated factors in patients with atrial fibrillation on antithrombotic therapy in Douala. The Douala atrial fibrillation registry is a prospective, observational cohort study of patients with atrial fibrillation followed by cardiovascular specialists in 3 specialized care centres. From January to April 2018, all patients with electrocardiographic diagnosis of atrial fibrillation, aged 21 years or older, were included in the registry provided their consent. The composite endpoint of heart failure, stroke, major bleeding, hospitalisation and mortality as well as their individual occurrence were assessed at 12 months. Of 113 participants that were included, 6(5.3%) were lost to follow-up. The mean age was 70 ± 12 years, with a female predominance (68%). After a mean follow-up time of 12.2 ± 0.7 months, 51 patients (47.7%) had at least one outcome. Hospitalisation, all-cause mortality, heart failure, stroke and major bleeding rates were 33.3%, 16.8%, 15.2%, 4.8% and 2.9% respectively. There was no significant difference in the composite outcome and mortality according to the antithrombotic treatment. Previous heart failure [aHR = 3.07, 95% CI (1.48–6.36) p = 0.003], new onset atrial fibrillation [aHR= 4.00, 95% CI (0.96–8.19) p < 0.001] and paroxystic atrial fibrillation [aHR= 3.74, 95% CI (1.33–10.53) p = 0.013] were significant predictors of outcome. Half of patients with atrial fibrillation in this registry developed an outcome after one year of follow-up, with heart failure, new onset and paroxystic atrial fibrillation being the main predicting factors. Diagnosing and managing atrial fibrillation in patients with heart disease should therefore be considered as a key priority. [ABSTRACT FROM AUTHOR]

Résumé La fermeture d'auricule gauche (FAG) est une alternative thérapeutique au traitement anticoagulant oral chez les patients avec fibrillation auriculaire non valvulaire. Cette intervention est en France réservée aux patients contre-indiqués aux AVK ou inhibiteurs directs de la thrombine. Elle permet de réduire le risque d'accidents ischémiques (par rapport à l'absence de traitement anticoagulant) et le risque d'évènements hémorragiques (par rapport à la poursuite du traitement anticoagulant) avec un risque limité de complications per-procédurales. Les patients âgés de plus de 75 ans présentent un risque ischémique mais aussi hémorragique plus important que les sujets plus jeunes, tout en étant régulièrement sous traités. Ces patients sont donc potentiellement ceux pouvant le plus bénéficier de la procédure. Les différentes études réalisées ont confirmé l'efficacité de la FAG dans cette population et sa sécurité à long terme, tout en soulignant le risque potentiel accru de complications péri-procédurales, notamment péricardique. Cependant, cette option reste tout à fait séduisante et pertinente pour la prise en charge de la fibrillation auriculaire dans cette population et devra s'intégrer dans une prise en charge globale pluridisciplinaire du patient. Abstract Left atrial appendage occlusion (LAAO) is an alternative option to oral anticoagulation therapy in patients with non-valvular atrial fibrillation. According to French regulations, this procedure is currently reserved for patients with formal contraindications to VKA and direct thrombin inhibitors. LAAO procedures reduce ischemic and stroke risks compared to no treatment and also reduce bleeding events compared to VKA therapy in eligible patients. The peri-procedural complications risk has been reported to be limited in the different series published so far. Although elderly patients (> 75 years) have either higher ischemic and bleeding risk than younger subjects, they hardly benefit from optimal anticoagulation. Thus, these subjects might greatly benefit from LAAO. Published studies reported excellent feasibility and efficiency of LAAO procedure in elderly patients. Yet there is a trend towards a higher incidence of peri-procedural complications (including tamponade), long-term safety is excellent and comparable to what is observed in patients < 75 years. Therefore, interventional percutaneous LAAO is an attractive strategy in elderly patients with atrial fibrillation that should be incorporated in a multidisciplinary management. [ABSTRACT FROM AUTHOR]

Résumé Les tachycardies supra-ventriculaires et leur traitement ont été peu étudiées chez les patients critiques. But de l’étude Évaluer l’efficacité et l’innocuité de la cardioversion pour tachycardie supra-ventriculaire en réanimation. Patients et méthode Inclusion prospective de tous les patients qui ont présenté des tachyarythmies supra-ventriculaire incluant la fibrillation auriculaire, prolongée ≥ 30 secondes dans une réanimation médico-chirurgicales, à l’exception du postopératoire de chirurgie cardiaque. Les médicaments anti-arythmiques et/ou les chocs électriques ont été administrés de façon libérale. Résultats Au cours de la période d’étude de 15 mois, 108/846 (12,8 %) patients ont présenté des tachycardies supra-ventriculaires. Les médicaments anti-arythmiques ont été administrés chez 78 patients (72 %) ; pour la plupart de l’amiodarone (92 %), et/ou du magnésium (23 %), ce qui a entraîné un taux de conversion en rythme sinusal global de 68 %. Le choc électrique externe a été utilisé chez 26 patients (24 %), (médicaments anti-arythmiques reçus préalablement chez 24 patients) avec un taux succès immédiat de 80,8 %. Conclusion Le choc électrique externe a été associé à une conversion soutenue en rythme sinusal à 80,8 %, chez des patients de réanimation avec tachycardie supra-ventriculaire, alors que la plupart d’entre eux avait déjà reçu des médicaments anti-arythmiques. Supra-ventricular tachyarrhythmia and its treatment have been poorly investigated in ICU patients. Aims To evaluate efficacy and safety of cardioversion for supra-ventricular tachyarrhythmia in the intensive care unit (ICU). Patients and methods Prospective inclusion of all patients who presented supra-ventricular tachyarrhythmias lasting ≥ 30 seconds in a single medico-surgical ICU, except cardiac surgery. Anti-arrhythmic drugs and/or direct-current cardioversion were administered on a liberal basis. Results During the 15-month study period, 108/846 patients (12.8%) experienced supra-ventricular tachyarrhythmias. Anti-arrhythmic drugs were administered in 78 patients (72%); mostly amiodarone (92%), and/or magnesium (23%), resulting in an overall conversion rate of 68%. Direct-current cardioversion was used in 26 patients (24%), (24 patients received drug enhancement by anti-arrhythmic drugs) with an immediate 80.8%-success rate. Conclusion Direct-current cardioversion was associated with sustained conversion to sinus rhythm in 80.8% of ICU patients with supra-ventricular tachyarrhythmias, although most of them had already received drug enhancement. [ABSTRACT FROM AUTHOR]

Résumé Les stimulateurs et défibrillateurs cardiaques ont des capacités holter permettant d’enregistrer la survenue d’épisodes d’arythmie. La question lorsqu’un épisode d’arythmie est enregistré par le stimulateur cardiaque est de savoir à partir de quelle durée ou de charge en arythmie que le risque d’AVC est augmenté et donc de l’indication de traitement anticoagulant. Cet article traite de l’attitude à avoir en cas de détection d’épisode rythmique rapide aux mémoires holter des prothèses implantables. Pacemakers and defibrillators have holter capabilities that can record episodes of arrhythmias. Different studies evaluated the effect on the risk of strokes of different durations of arrhythmias. The question of the management of patients depending on the duration of the arrhythmia episode is addressed in this article depending on the duration of the episode and the arrhythmia burden. [ABSTRACT FROM AUTHOR]

Résumé La fibrillation auriculaire est l’arythmie cardiaque la plus fréquemment observée en pratique quotidienne. Elle est grevée d’une morbi-mortalité importante, en particulier de mort subite, d’insuffisance cardiaque et d’accident vasculaire cérébral. La validation de marqueurs non invasifs dans le diagnostic de l’insuffisance cardiaque à fraction d’éjection préservée et dans la stratification du risque apparaît intéressante dans ce contexte. L’indice E/e’ en Doppler tissulaire spectral a été validé dans l’estimation des pressions de remplissage du ventricule gauche indépendamment du rythme cardiaque. Une valeur de E/e’ septal > 11 est rapportée comme prédictive d’une pression diastolique ventriculaire gauche > 15 mmHg chez les patients en fibrillation auriculaire. De plus, plusieurs études ont rapporté la pertinence clinique de sa mesure au repos comme à l’effort dans le diagnostic et le pronostic de l’insuffisance cardiaque à fraction d’éjection préservée chez les patients en arythmie. Cet indice offre parallèlement une information pronostique essentielle chez les patients en fibrillation auriculaire. Enfin, une valeur pathologique de E/e’ est prédictive de récidive de la fibrillation auriculaire après cardioversion ou procédure d’ablation. En conclusion, nous recommandons la mesure de E/e’ chez tous les patients en fibrillation auriculaire bénéficiant de la réalisation d’une échocardiographie Doppler transthoracique. Atrial fibrillation is the most common cardiac rhythm disorder encountered in daily clinical practice. It carries high morbidity and mortality rates, mainly related to sudden death, heart failure and stroke. Validation of noninvasive markers in the diagnosis of heart failure with preserved ejection fraction and risk stratification is therefore attractive in this clinical setting. The spectral tissue Doppler-derived E/e’ ratio is a simple and user-friendly index which has been validated in the assessment of left ventricular diastolic pressures, regardless of rhythm. A septal E/e’ > 11 is associated with invasive left ventricular diastolic pressures > 15 mmHg in patients with atrial fibrillation. Several studies have reported the clinical relevance of abnormal values of E/e’ at rest and during exercise in the diagnosis and risk stratification of heart failure with preserved ejection fraction in patients with atrial fibrillation. There is now convincing evidence that increased E/e’ is associated with adverse outcome in patients with atrial fibrillation and predicts the recurrence of arrhythmia after cardioversion or catheter ablation. In conclusion, we recommend the measurement of E/e’ in each patient with atrial fibrillation referred for clinically indicated transthoracic Doppler echocardiography. [ABSTRACT FROM AUTHOR]

Résumé But de l’étude L’incidence de l’insuffisance cardiaque est en augmentation. L’accès aux soins palliatifs reste difficile compte tenu de son évolution imprédictible. Cette étude avait pour objectif de décrire les caractéristiques des patients en IC ayant fait l’objet d’une limitation de soins et de les comparer à l’ensemble de la population hospitalisée pour insuffisance cardiaque sur une même période. Patients et méthodes Les patients admis pour insuffisance cardiaque dans le service entre 2009 et 2013 ont été inclus rétrospectivement. Parmi ces patients, nous avons identifié ceux qui ont fait l’objet d’une limitation de soins. Une feuille personnalisée sur l’intensité du niveau de soins était établie en réunion pluridisciplinaire. Résultats Sur 940 patients inclus, 42 (4,5 %) ont fait l’objet d’une limitation de soins. La cardiopathie ischémique était la plus fréquente ( n = 19 ; 45,2 %). La dysfonction ventriculaire droite ( n = 34 ; 80,9 %) était souvent associée à une arythmie supra-ventriculaire ( n = 28 ; 66,7 %). Sur les 42 patients, 28 (57,1 %) sont décédés dans le service, 9 (21,4 %) ont été transférés en soins palliatifs et 8 (19,1 %) sont retournés à domicile ou transférés en convalescence. Le délai entre la prise en charge et le décès était en moyenne de 6 jours. La mortalité intra-hospitalière du groupe témoin était de 6,8 %. Conclusion La prise en charge palliative en cardiologie est souvent sous-utilisée et tardive car difficilement adaptable à l’insuffisance cardiaque. Il est nécessaire d’identifier les facteurs pronostiques de ces patients et de leur proposer en amont un projet thérapeutique globale et un niveau d’intensité de soins personnalisé. Purpose Advanced heart failure incidence is in progression. Palliative care access remains difficult due to its unpredictable course. The aim of this study was to describe the characteristics of patients admitted in Cardiology Intensive Care Unit for advanced heart failure who received palliative care and compare them to the whole population of acute heart failure hospitalized in the same period. Patients and methods The patients hospitalized for acute heart failure were retrospectively included from 2009 to 2013. We identified among them those who received palliative care. Specific caring was decided in pluridisciplinary meeting. Results On 940 patients included, 42 patients (4.5%) receive palliative care. Ischemic heart disease was the main etiology ( n = 19; 45.2%). Right ventricular dysfunction ( n = 34; 80.9%) was associated with supra-ventricular arrhythmia ( n = 28; 66.7%). Twenty-eight patients (57.1%) have died in hospital, 9 (21.4%) were referred to a palliative care unit and 8 (19.1%) was discharged or referred to a rehabilitation center. Time between inclusion and death was 6 days on average. Intra-hospital mortality in control group was 6.8%. Conclusion Palliative care in cardiology is uncommon and has often been too late because of its poor adaptability to advanced heart failure. It is, as consequence, necessary to identify the prognostic factors of these patients in order to propose a personalized care and to adjust the intensity of care ahead of the terminal evolution of heart failure. [ABSTRACT FROM AUTHOR]

Résumé: L’accident vasculaire cérébral (AVC) est une pathologie extrêmement fréquente dont l’important retentissement fonctionnel et financier nécessite une intense politique de prévention. Cette stratégie inclut la prévention des complications thromboemboliques de la fibrillation auriculaire. La prise en charge préthérapeutique de la fibrillation auriculaire comprend l’évaluation du risque thromboembolique par le score CHA2DS2VASc et l’évaluation du risque hémorragique par le score HASBLED. Le traitement préventif standard est le traitement anticoagulant par antivitamine K. Néanmoins, nombre de patients éligibles à ce traitement n’en bénéficient pas à cause d’un risque hémorragique trop important ; dans d’autres cas, la récidive thromboembolique survient malgré un traitement anticoagulant bien conduit. Une nouvelle alternative non médicamenteuse est proposée pour ces situations cliniques : la fermeture percutanée de l’auricule gauche. Les études réalisées ont évalué la faisabilité, l’efficacité et la sécurité de 3 dispositifs : le dispositif PLAATO, le WATCHMAN© et l’AmplatzerCardiacPlug™. L’étude prospective randomisée multicentrique PROTECT-AF a démontré une non-infériorité du dispositif WATCHMAN© par rapport au traitement conventionnel par warfarine. Pourtant ce constat doit faire l’objet d’une réflexion médicale visant à déterminer la population cible pouvant réellement bénéficier de traitement. Actuellement, des programmes d’évaluation clinique ont démarré en France avec l’objectif de préciser l’indication de ce traitement non médicamenteux de l’AVC. [ABSTRACT FROM AUTHOR]

Abstract: With its high prevalence and well-known thromboembolic risk, atrial fibrillation (AF) is a crucial component of the 2010–2014 actions plan, ongoing in France to reduce the annual incidence of stroke. The stroke risk is stratified well with the CHA2DS2-VASc score. With the current guidelines, most patients with AF should be on oral anticoagulant regimen, a treatment recognized as effective but whose bleeding risks limit its use. In clinical practice, warfarin is often not prescribed in patients with high risk of stroke. Thus, the exploration of new ways in preventing thromboembolic events in patients with AF is needed. Beside new more convenient anticoagulant agents, the exclusion of the left atrial appendage recognized as main source of thrombi, may be an alternative in patients with both high risk of thrombotic and haemorrhagic events. Surgical experience showed that the results depend on the quality of the exclusion. For over the past 10years, several percutaneous exclusion systems of the left atrial appendage have been developed. A randomized study (PROTECT AF) demonstrated the non-inferiority of the percutaneous exclusion in comparison with the warfarin. However, the place of this interventional therapy remains to be clarified, particularly the definition of the target population. This often multidisciplinary approach will have to be accompanied by a reduction of periprocedural complications, increase in rate of complete occlusion, and enough long clinical follow-up to assess the efficiency of this strategy. [Copyright &y& Elsevier]

Abstract: Thyrotoxicosis is underdiagnosed because of its low occurrence in series from Africa. The aim of this study was to evaluate the frequency, the demographic data, and the etiological aspects of thyrotoxicosis among hyperthyroidy. Thirty-six patients with thyrotoxicosis (group I) gathered during a period of four years was analysed, as well as 180 hyperthyroidy cases (group II). Cardiothyrotoxicosis was observed with a frequency of 16.6%. The mean age was respectively of 44.5±13.3 versus 32.8±11.4 years (p <10 −6). Cardiothyrotoxicosis was related to multinodular goitres (18 cases), a Basedow disease (14 cases), a toxic adenoma (four cases), while the principal cause of hyperthyroidy was toxic adenoma followed by the Basedow disease (72 cases, 40%). Different modes of presentation of cardiothyrotoxicosis were found: cardiac heart failure in 27 cases (75%), permanent atrial fibrillation in 22 cases (61.1%), atrial flutter in two cases, coronary insufficiency in four cases, ventricular extrasystoli (trigeminism) in two cases, second auriculoventricular block in two cases, dilated myocardiopathy in 10 cases (27.7%), ischemic myocardiopathy in four cases, severe mitral regurgitation in one case. This study confirms the relative frequency of cardiothyrotoxicosis, the proportionally weak place of Basedow disease among hyperthyroidy’s causes, and role of associated cardiac disease to the hyperthyroid. [Copyright &y& Elsevier]

Abstract: The significance of atrial fibrillation (AF) in idiopathic dilated cardiomyopathy (IDCM) remains discussed. The purpose of the study was to evaluate the clinical significance of permanent atrial fibrillation in patients with IDCM. Methods: Systematic noninvasive and invasive studies including Holter monitoring, measurement of left ventricular ejection fraction (LVEF), electrophysiological study and coronary angiography were performed in 323 patients with IDCM; all patients had a left ventricular ejection fraction (LVEF)<40%. The studies were indicated for spontaneous ventricular tachycardia (VT) in 69 patients, syncope in 103 patients and nonsustained VT on Holter monitoring in 151 asymptomatic patients. Sixty-five patients were in permanent AF (group I). Remaining patients were in sinus rhythm at the time of evaluation (group II). Programmed ventricular stimulation using up to 3 extrastimuli in control state and if necessary after isoproterenol was systematic. Patients were followed 3±2 years. Results: Mean age was significantly older in group I (61±8 years) than in group II (52±12) (P <0.01). Syncope (31 vs 36%), spontaneous sustained VT (18 vs 23%); mean LVEF (28±9% vs 29±9%), VT induction (25 vs 35%) were similar in both groups. During the follow-up, there were no statistical differences between groups I and II concerning each event: sudden death occurred in 13 patients, 1.5% of group I patients and 5% of group II patients (NS); a death related to heart failure occurred 22 patients, 5% of group I patients and 7% of group II patients (NS); heart transplantation was performed in 13 patients, 8% of group I patients and 3% of group II patients (NS). Conclusions: An older age is the only significant clinical factor associated with the presence of a permanent atrial fibrillation in idiopathic dilated cardiomyopathy. The presence of permanent AF does not increase the induction of a sustained ventricular tachycardia and does not affect the general prognosis of IDCM. [Copyright &y& Elsevier]

Abstract: 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 alternans 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. [Copyright &y& Elsevier]

Calpains are a large family of cytosolic cysteine proteases composed of at least fourteen distinct isoforms. The family can be divided into two groups on the basis of distribution: ubiquitous and tissue-specific. Our current knowledge about calpains properties apply mainly to the ubiquitous isozymes, micro- and milli-calpain (classic calpains). These forms are activated after autolysis. Translocation and subsequent interactions with phospholipids of these enzymes increase their activity. Calpains are able to cleave a subset of substrates, as enzymes, structural and signalling proteins. Cardiac pathologies, such as heart failure, atrial fibrillation or clinical states particularly ischemia reperfusion, are associated with an increase of cytosolic calcium and in this regards, calpain activation has been evoked as one of the mediators leading to myocardial damage. Calpain activities have been shown to be increased in hearts experimentally subjected to ischemia reperfusion or during hypertrophy, but also in atrial tissue harvested from patients suffering from atrial fibrillations. These activities have been related to an increase of the proteolysis of different myocardial components, particularly, troponins, which are major regulators of the contraction of cardiomyocytes. Moreover, recent works have demonstrated that calpains are involved in the development of myocardial cell death by necrosis or apoptosis. [Copyright &y& Elsevier]

In a registry of 250 patients treated for atrial fibrillation (160 recurrent, 90 permanent forms), we prospectively looked for associated risk factors for cerebrovascular complications. After a 4-years follow-up, 19 patients had presented a cerebral accident (13 strokes, 4 transient ischemic attacks, 2 cerebral hemorrhages). Prognostic factors for cerebrovascular complications were hypertension, valvular heart disease, and age ≥70 years. When restricting the analysis to stroke and transient ischemic attacks, prognostic factors were limited to hypertension and age ≥70 years. In conclusion, hypertension and age ≥70 years are the main independent risk factors for cerebral ischemic attacks in out-of-hospital patients treated for atrial fibrillation. [Copyright &y& Elsevier]

Etiology of atrial fibrillation remains largely unknown. Molecular genetics is a powerful tool that may help to identify underlying mechanisms of the arrhythmia. As a matter of fact, a major step forward was the recent identification of the KCNQ1 gene coding a subunit of a potassium channel in IKS current as responsible for idiopathic atrial fibrillation in a familial autosomal dominant form. The KCNQ1 gain-of-function mutation may induce a shortening in action potential and in effective refractory periods leading to the initiation and persistence of atrial fibrillation. In the multifactorial forms of the disease, by far the most frequent, susceptibility genes and modifier genes are also currently being identified. This better understanding of the disease leads to new perspectives, particularly for therapeutists, and would enable them to work with more interest. [Copyright &y& Elsevier]

Atrial fibrillation is the most frequent arrhythmia in the general population, and it increases with age. The prevention of thromboembolic events, the most important complication of the disease, is a major problem. Antivitamin K is to date the most efficient therapeutic class for the prevention of these events. Although they allow a decrease in stroke by at least 50%, they are associated with an increased haemorrhagic risk (annual incidence ranging from 7% to 22%). This risk makes oral anticoagulant treatment underused in high risk patients, particularly in the elderly populations. Optimisation of the management of patients with atrial fibrillation should be based on an individual evaluation of the thromboembolic and haemorrhagic risks. Several stratifications have been performed to identify the risk predictors of thromboembolic and haemorrhagic events in patients with atrial fibrillation, allowing an evaluation of the benefit/risk ratio of antithrombotic treatments and using indices such as NNT (number of patients needed to treat to avoid an event) and NNH (number of patients needed to harm with haemorrhagic event). The available data do not allow, however, to evaluate precisely the individual level of haemorrhagic risk. [Copyright &y& Elsevier]

The possibility of curing patients suffering from paroxysmal atrial fibrillation using a radiofrequency ablation treatment is a major change in the management of this arrhythmia. Pulmonary vein disconnection is efficient and safe after a learning curve of the operator. This pulmonary vein isolation is the first and mandatory step allowing disappearance of atrial fibrillation in 70% of the patients. Modification in fibrillatory substrate using linear lesions increases the rate success to 75% in chronic atrial fibrillation and to 82% in paroxysmal atrial fibrillation. The radiofrequency ablation of atrial fibrillation should be considered as a surgical treatment without an open heart, isolating structures and cutting tissues are technical improvements (new radiofrequency catheters) will probably facilitate in the future. Some comparative studies with medical treatment are currently evaluating their efficacy, safety and respective cost and they may lead to a considerable increase in the number of patients who could benefit from these curative treatments. [Copyright &y& Elsevier]

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. [Copyright &y& Elsevier]

Aim. – Supraventricular arrhythmia is a major public health problem because of its prevalence and clinical consequences. The first step of the treatment usually consists in restoring sinusal rhythm. The aim of this study is to evaluate results and predictive factors of success of electrical cardioversion.Methods. – We studied a series of 143 consecutive electric cardioversion preformed in 131 French patients.Results. – The rate of successful direct current cardioversion was 91.2%. Negative predictive factors are the height body mass index and the age of arrhythmia. Atrial flutter is a predictive factor of success. These results agree with published results. Our study highlights the interest of some nonantiarrhythmic drugs received by the patient during the period before the direct current cardioversion. Thus, a spironolactone treatment appears to be a new predictive factor of the success of electrical cardioversion (success in patients treated with spironolactone: 100% vs 89% without, P = 0.04).Conclusions. – Our results agree with usual predictive factors of the success of cardioversion. Nevertheless, a new approach is that of the positive effect of spironolactone on cardioversion. A prospective randomized study is necessary to confirm this result. [Copyright &y& Elsevier]

Abstract: Guidelines published from the European Society of Cardiology/American Heart Association, and from the American College of Chest Physicians, clarified the strategy of antithrombotic treatment in AF, which is based on the presence of risk factors for thromboembolism. The European guidelines have been updated in 2010 and differ from the ACCP guidelines. They integrated the CHA2DS2Vasc score and modified accordingly the previous recommendations based on the CHADS2score, which allows physicians to classify patients as at low, moderate or high risk, according to their individual risk characteristics. Recently published registries confirm under-prescription of VKA treatment in the ‘real world’, even in patients at high thromboembolic risk, and over-prescription for at least one-third of patients at low risk. Therefore reducing the risk of thromboembolism should be the physicians’primary aim, particularly with the advent of alternative treatments and the development of new antithrombotic drugs such as oral thrombin and factor Xa inhibitors, which are currently being evaluated in clinical trials. [ABSTRACT FROM AUTHOR]

Abstract: 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. [ABSTRACT FROM AUTHOR]

Abstract: In case of persistent and symptomatic atrial fibrillation, a pharmacological cardioversion under effective anticoagulation treatment may be performed according to current guidelines. In the absence of return to sinus rhythm, a Direct-Current cardioversion can be performed. After returning to sinus rhythm will arise the question of anticoagulation and antiarrhythmic drugs treatments that will be most often longterm pursued. [Copyright &y& Elsevier]

Abstract: Atrial fibrillation is the most common cardiac arrhythmia. The identification of familial forms of atrial fibrillation as well as epidemiological studies have confirmed the presence of a genetic background. Familial forms are rare diseases, and the common form is a multifactorial and probably multigenic disease largely modulated by environmental factors. New research developments, based on GWAS studies of well define large cohorts, should, in the near future, help to better characterize the different genetic profiles of this disease, the first step for the identification of new therapeutic targets. [Copyright &y& Elsevier]

Abstract: The development of new antiarrhythmic drugs is mainly aimed to treat atrial fibrillation, because of its prevalence and major consequences in terms cerebral vascular thrombosis. Specific blockade of I Na et I K, even if efficacious, have previously shown to be proarrhythmogenic, with a global impairment of the cardiac patient''s outcome. This lead to the development of new drugs, selectively targeting atrial currents such as I Kur ou I KAch. The efficacy of amiodarone in treatment of atrial fibrillation has also yielded a whole array of new antiarrhythmic drugs targeting both these atrial currents but also sharing amiodarone pharmacodynamics properties. This renders the Vaughan-Williams classification ill-adapted for such drugs. [Copyright &y& Elsevier]

Abstract: Although the important progress in the curative treatment of atrial fibrillation, the indications of the regularisation of the first episode and of the preventive treatment remain difficult. Without real proofs on the interest of maintain in sinus rhythm, the indications depend on the age of the patient, the clinical tolerance and the objective impact on left ventricular ejection fraction. [Copyright &y& Elsevier]

Abstract: Atrial Fibrillation Surgery is wide spread today but the indications are still limited to associated procedures with other cardiac surgery. Minimally invasive approach is less aggressive and could be proposed to complex lone AF which are still resistant to percutaneous ablations. [Copyright &y& Elsevier]

Abstract: After cardioversion of atrial fibrillation, structural and electrophysiologic remodelling of the atria is implicated in the arrhythmia recurrences despite antiarrhythmic drug treatment. Strategies targeting this substrate have therefore been proposed. In this view, Renin angiotensin system inhibition and drugs targeting inflammation and oxidative injury are the most promising strategies up to now. We discuss here the rationale and evidence which are behind these therapeutic approaches. [Copyright &y& Elsevier]