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Objectives Using French transcatheter aortic valve replacement (TAVR) registries linked with the nationwide administrative databases, the study compared the rates of long-term mortality, bleeding, and ischemic events after TAVR in patients requiring oral anticoagulation with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). Background The choice of optimal drug for anticoagulation after TAVR remains debated. Methods Data from the France-TAVI and FRANCE-2 registries were linked to the French national health single-payer claims database, from 2010 to 2017. Propensity score matching was used to reduce treatment-selection bias. Two primary endpoints were death from any cause (efficacy) and major bleeding (safety). Results A total of 24,581 patients who underwent TAVR were included and 8,962 (36.4%) were treated with OAC. Among anticoagulated patients, 2,180 (24.3%) were on DOACs. After propensity matching, at 3 years, mortality (hazard ratio [HR]: 1.37; 95% confidence interval [CI]: 1.12-1.67; P Conclusions In these large multicenter French TAVR registries with an exhaustive clinical follow-up, the long-term mortality and major bleeding were lower with DOACs than VKAs at discharge. The present study supports preferential use of DOACs rather than VKAs in patients requiring oral anticoagulation therapy after TAVR.

MitraClip (Abbott Laboratories, Abbott Park, IL) is validated in high-risk patients with severe degenerative mitral regurgitation (MR); however, it is not well established for functional MR in hypertrophic cardiomyopathy (HCM). We share a case of a 68-year-old man with HCM hospitalized for multiple incidents of acute pulmonary edema caused by a dynamic MR and successfully treated with the MitraClip device. Novel teaching points emerging from this case are that MRs in HCM can often be explained by mixed mechanisms, and properly identifying the MR mechanism is essential to choose optimal treatment. Furthermore, MitraClip can simultaneously treat MR secondarily to annular dilation and systolic anterior motion.

Open heart transcatheter mitral valve implantation using the Edwards‐Sapien 3 for mitral annular calcification is a safe procedure, because surgeons do not have to decalcify. And also, surgeons can resect the anterior mitral leaflet to prevent left ventricular outflow tract obstruction and deploy the valve under direct visualization.

A comprehensive understanding of the interaction between triggers and electrical substrates leading to ventricular fibrillation (VF) and sudden cardiac arrest is lacking, and electrical substrates are difficult to detect and localize with current clinical tools. Here, we created repolarization time (RT) dispersion by regional drug infusion in perfused explanted human (n = 1) and porcine (n = 6) hearts and in a computational model of the human ventricle. Arrhythmia induction was tested with a single ventricular extrastimulus applied at the early or late RT region. Arrhythmias could only be induced from early RT regions. Vulnerability to VF increased with RT gradient steepness and with larger areas of early RT, but not with markers on the body-surface electrocardiogram. Noninvasive electrocardiographic imaging was performed in survivors of idiopathic VF (n = 11), patients with frequent premature ventricular complexes (PVCs) but no history of sudden cardiac arrest (n = 7), and controls (n = 10). In survivors of idiopathic VF, RT gradients were steeper than in controls, without differences in the clinical electrocardiogram, consistent with the ex vivo results. Patients with idiopathic VF also showed local myocardial regions with distinctly early-versus-late RT that were more balanced in size than in controls. Premature beats originated more often from the early RT regions in idiopathic VF survivors than in patients with frequent PVCs only. Thus, idiopathic VF emerges from the spatiotemporal interaction of a premature beat from an early-repolarization region with critical repolarization dispersion in that region. Electrocardiographic imaging can uncover the co-occurrence of these abnormalities.

Mitral valve replacement (MVR) using a prosthesis of transcatheter aortic valve implantation for mitral annular calcification (MAC) is an alternative procedure which is very different from a conventional MVR and is safe. Acceptable results including mortality and morbidity have been reported. We report the case of a male patient treated with this procedure. There was a risk of left ventricular rupture due to extensive decalcification, so we performed transcatheter mitral valve implantation (TMVI). Since he had a history of surgical aortic valve replacement (AVR), we chose open-heart transseptal approach so as not to interfere with the aortic prosthesis. TMVI has a risk of an iatrogenic left ventricular outflow tract (LVOT) obstruction. Using open-heart transseptal approach, we could easily check an anterior commissure of mitral annulus to prevent LVOT obstruction.

Background Dispersion and gradients in repolarization have been associated with life‐threatening arrhythmias, but are difficult to quantify precisely from surface electrocardiography. The objective of this study was to evaluate electrocardiographic imaging (ECGI) to noninvasively detect repolarization‐based abnormalities. Methods and Results Ex vivo data were obtained from Langendorff‐perfused pig hearts (n=8) and a human donor heart. Unipolar electrograms were recorded simultaneously during sinus rhythm from an epicardial sock and the torso‐shaped tank within which the heart was suspended. Regional repolarization heterogeneities were introduced through perfusion of dofetilide and pinacidil into separate perfusion beds. In vivo data included torso and epicardial potentials recorded simultaneously in anesthetized, closed‐chest pigs (n=5), during sinus rhythm, and ventricular pacing. For both data sets, ECGI accurately reconstructed T‐wave electrogram morphologies when compared with those recorded by the sock (ex vivo: correlation coefficient, 0.85 [0.52–0.96], in vivo: correlation coefficient, 0.86 [0.52–0.96]) and repolarization time maps (ex‐vivo: correlation coefficient, 0.73 [0.63–0.83], in vivo: correlation coefficient, 0.76 [0.67–0.82]). ECGI‐reconstructed repolarization time distributions were strongly correlated to those measured by the sock (both data sets, R 2 ≥0.92). Although the position of the gradient was slightly shifted by 8.3 (0–13.9) mm, the mean, max, and SD between ECGI and recorded gradient values were highly correlated ( R 2 =0.87, 0.75, and 0.86 respectively). There was no significant difference in ECGI accuracy between ex vivo and in vivo data. Conclusions ECGI reliably and accurately maps potentially critical repolarization abnormalities. This noninvasive approach allows imaging and quantifying individual parameters of abnormal repolarization‐based substrates in patients with arrhythmogenesis, to improve diagnosis and risk stratification.

International audience; Objective: The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) initially developed for predicting early postoperative mortality of all types of cardiac surgery, is less able to predict, more specifically, long-term outcomes after aortic valve replacement (AVR). The study authors here evaluated the risk factors for three-year mortality after isolated aortic valve replacement (AVR) for severe calcified tricuspid aortic valve stenosis and compared them with EuroSCORE II to predict long-term outcomes. Design: A retrospective study. Setting: A university teaching hospital. Participants: This study included 1,101 adults who underwent isolated AVR for severe calcified tricuspid aortic valve stenosis between September 2010 to June 2015. Interventions: None. Measurements and Main Results: The primary endpoint was that of three-year all-cause mortality after AVR. By three years, 168 patients (15.3%) had died. Risk factors for all-cause mortality were: male gender (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.21-2.62; p < 0.01), peripheral arterial disease (OR = 1.77; 95% CI = 1.08-2.92; p = 0.03), age (OR = 1.06 per year increase; 95% CI =1.04-1.09; p < 0.01), pulmonary artery systolic pressure (OR = 1.02 per mmHg increase; 95% CI = 1.01-1.03; p < 0.01), platelet count (OR = 1.003 per G/L increase; 95% CI = 1.000-1.005; p = 0.04), and valve area (OR = 0.97 per cm 2 /m 2 increase; 95% CI= 0.95-0.99; p < 0.01). The area under the receiver operating characteristic curves were 0.67 (95% CI = 0.60-0.75) and 0.60 (95% CI = 0.56-0.65) for the authors' logistic regression model and EuroSCORE II, respectively (p = 0.11). Conclusions: The study authors identified six independent risk factors for three-year mortality after isolated AVR. The logistic regression model had relatively modest predictive performance for three-year mortality.

Objectives Although the impact of prosthesis–patient mismatch (PPM) on survival has been widely studied, there has been little debate about whether the current definition of PPM truly reflects hemodynamic obstruction. This study aimed to validate the categorization of indexed effective orifice area (EOAi) for the classification of PPM. Methods In total, 2171 patients who underwent aortic valve replacement with a surgical stented bioprosthesis in 5 trials (CoreValve US High-Risk, SURTAVI [Surgical Replacement and Transcatheter Aortic Valve Implantation Trial], Evolut Low Risk, PERIGON [PERIcardial SurGical AOrtic Valve ReplacemeNt] Pivotal Trial for the Avalus valve, and PERIGON Japan) were used for this analysis. The echocardiographic images at the 1-year follow-up visit were evaluated to explore the association between EOAi and mean aortic gradient and its interaction with other patient characteristics, including obesity. In addition, different criteria of PPM were compared with reflect elevated mean aortic gradients (≥20 mm Hg). Results A relatively smaller exponential decay in mean aortic gradient was found for increasing EOAi, as the slope on the log scale was –0.83 versus –2.5 in the publication from which the current cut-offs for PPM originate. The accuracy of the American Society of Echocardiography, Valve Academic Research Consortium-2, and European Association of Cardiovascular Imaging definitions of PPM to reflect elevated mean aortic gradients was 49%, 57%, and 57%, respectively. The relation between EOAi and mean aortic gradient was not significantly different between obese and non-obese patients (P = .20). Conclusions The use of EOAi thresholds to classify patients with PPM is undermined by a less-pronounced exponential relationship between EOAi and mean aortic gradient than previously demonstrated. Moreover, recent adjustment for obesity in the definition of PPM is not supported by these data.

Objectives The authors report the first acute clinical experience of atrial fibrillation ablation with PEF—both epicardial box lesions during cardiac surgery, and catheter-based PV isolation. Background Standard energy sources rely on time-dependent conductive heating/cooling and ablate all tissue types indiscriminately. Pulsed electric field (PEF) energy ablates nonthermally by creating nanoscale pores in cell membranes. Potential advantages for atrial fibrillation ablation include: 1) cardiomyocytes have among the lowest sensitivity of any tissue to PEF—allowing tissue selectivity, thereby minimizing ablation of nontarget collateral tissue; 2) PEF is delivered rapidly over a few seconds; and 3) the absence of coagulative necrosis obviates the risk of pulmonary vein (PV) stenosis. Methods PEF ablation was performed using a custom over-the-wire endocardial catheter for percutaneous transseptal PV isolation, and a linear catheter for encircling the PVs and posterior left atrium during concomitant cardiac surgery. Endocardial voltage maps were created pre- and post-ablation. Continuous and categorical data are summarized and presented as mean ± SD and frequencies. Results At 2 centers, 22 patients underwent ablation under general anesthesia: 15 endocardial and 7 epicardial. Catheter PV isolation was successful in all 57 PVs in 15 patients (100%) using 3.26 ± 0.5 lesions/PV: procedure time 67 ± 10.5 min, catheter time (PEF catheter entry to exit) 19 ± 2.5 min, total PEF energy delivery time Conclusions These data usher in a new era of tissue-specific, ultrarapid ablation of atrial fibrillation.

OBJECTIVES Transaortic (TAo) access for transcatheter aortic valve implantation (TAVI) is an alternative to the conventional transfemoral or transapical routes. Data comparing the characteristics and outcomes of TAo-TAVI using the SAPIEN XT and SAPIEN 3 heart valves are scarce. The objective of the current analysis was to provide such information. METHODS ROUTE is an international, prospective, observational registry. Patients with severe calcific aortic stenosis scheduled for TAo-TAVI with an Edwards SAPIEN XT or a SAPIEN 3 heart valve were consecutively enrolled at 22 centres across Europe between February 2013 and February 2015. Periprocedural, in-hospital and 30-day complication rates were assessed. RESULTS Of the 301 patients included, 126 (41.9%) received a SAPIEN 3 and 175 (58.1%) a SAPIEN XT. The SAPIEN 3 was associated with shorter procedure time (101 ± 35 vs 111 ± 40 min; P = 0.031) and a lower quantity of contrast agent used (87 ± 43 vs 112 ± 50 ml; P

Background HeartMate 3 is a left ventricular assist device, composed of a centrifugal pump. It can be applied as a myocardial recovery, a bridge to transplant, or a destination therapy, in the treatment of patients with left ventricular heart failure. Methods Herein we describe a technique applied against a giant aneurysmal dilatation, which combines a surgical device implantation and a left ventricular reconstruction using a double patch. Results The patch minimizes thrombotic risk thanks to its internal bovine pericardium layer, which is in contact with blood. Conclusions The outlined technique is relatively reproducible and safe in a selected group of patients, as it employs a high-quality device and enables the restoration of an appropriate ventricular geometry.

To provide a model close to the human heart, and to study intrinsic cardiac function at the same time as electromechanical coupling, we developed a magnetic resonance (MR)-compatible setup of isolated working perfused pig hearts. Hearts from pigs (40 kg, n = 20) and sheep ( n = 1) were blood perfused ex vivo in the working mode with and without loaded right ventricle (RV), for 80 min. Cardiac function was assessed by measuring left intraventricular pressure and left ventricular (LV) ejection fraction (LVEF), aortic and mitral valve dynamics, and native T1 mapping with MR imaging (1.5 Tesla). Potential myocardial alterations were assessed at the end of ex vivo perfusion from late-Gadolinium enhancement T1 mapping. The ex vivo cardiac function was stable across the 80 min of perfusion. Aortic flow and LV-dP/d tmin were significantly higher ( P < 0.05) in hearts perfused with loaded RV, without differences for heart rate, maximal and minimal LV pressure, LV-dP/d tmax, LVEF, and kinetics of aortic and mitral valves. T1 mapping analysis showed a spatially homogeneous distribution over the LV. Simultaneous recording of hemodynamics, LVEF, and local cardiac electrophysiological signals were then successfully performed at baseline and during electrical pacing protocols without inducing alteration of MR images. Finally, 31P nuclear MR spectroscopy (9.4 T) was also performed in two pig hearts, showing phosphocreatine-to-ATP ratio in accordance with data previously reported in vivo. We demonstrate the feasibility to perfuse isolated pig hearts in the working mode, inside an MR environment, allowing simultaneous assessment of cardiac structure, mechanics, and electrophysiology, illustrating examples of potential applications.

The onset of right ventricular dysfunction in patients presenting with congenital heart disease is associated with a dismal long-term outcome and often represents a therapeutic dead end. Our study had several objectives: (1) to analyse the anatomical, functional, histological and cellular characteristics of an animal model of repaired tetralogy of Fallot with right ventricular dysfunction (2) to test the new electrical treatment known as cardiac contractility modulation in this animal model. Seven sheep underwent a first surgery at the age of three weeks aiming to mimic the characteristics of a repaired tetralogy of Fallot. Five controls were sham-operated. Experimental studies were performed 12 months after the initial operation. The hemodynamic, echocardiographic, and mitochondrial function studies were carried out before and after cardiac contractility modulation in closed- and open-chest conditions. In this animal model of right ventricular dysfunction, short-term cardiac contractility modulation was associated with a significant improvement in (a) right ventricular function, as evidenced by a significant increase in right ventricular dP/dt (p

OBJECTIVES There is lack of data regarding the longer-term outcomes of patients undergoing transaortic (TAo) transcatheter aortic valve implantation (TAVI). We aimed to provide a contemporary snapshot of the types and frequencies of events in the year following TAo-TAVI. METHODS The Registry of the Utilization of the TAo-TAVI approach using the Edwards SAPIEN Valve (ROUTE) is a multicentre, European, prospective, observational registry of aortic stenosis patients undergoing TAo-TAVI. Patients were grouped according to the composite end point death, myocardial infarction, stroke/transient ischaemic attack, major vascular complications, life-threatening bleeding, acute kidney injury (AKI) and/or cardiovascular rehospitalization. RESULTS Two hundred and fifty-three patients with a mean age of 81.5 ± 5.8 years were included, of whom 89 (35.2%) patients met the composite end point (the event group) and 164 (64.8%) patients did not (the event-free group). New York Heart Association (NYHA) class III/IV (85.2% vs 71.8%, P = 0.017), Canadian Cardiovascular Society angina class III/IV (22.6% vs 11.4%; P = 0.021), pulmonary disease (32.6% vs 18.9%; P = 0.015) and renal insufficiency (15.7% vs 3.0%; P

Background: A large Dispersion of Repolarization (DoR) is associated with an increased arrhythmogenic risk. This can be measured clinically by calculating the Activation Recovery Interval (ARI) to estimate Action Potential Duration (APD). However, the ability of ARI to accurately predict APD dispersion in patients with repolarization abnormality has not been determined. Objective: Compare ARI calculated from patients with optical mapping of human hearts to establish the validity of ARI as a surrogate for APD. Methods: Optical mapping (OM) was performed on the left ventricles of 4 explanted human hearts. APD and repolarization times were measured endo- and epicardially on the anterior of the LV. Electroanatomic mapping was performed with CARTO over the entire endo- and epicardial surfaces of 3 patients. Activation and repolarization were calculated, dispersion of ARI was measured. Results: APD and ARI were consistent between mapping methods over most of the sub-regions studied. Epicardium ARI dispersion was consistently higher than that of the endocardium in both OM and CARTO datasets. Conclusion: APD distribution, and consequently DoR, agree between mapping methods. Measuring DoR by ARI accurately assesses the underlying repolarization abnormalities in patients.

Supplemental Digital Content is available in the text., Background: Sudden cardiac death because of ventricular fibrillation (VF) is commonly unexplained in younger victims. Detailed electrophysiological mapping in such patients has not been reported. Methods: We evaluated 24 patients (29±13 years) who survived idiopathic VF. First, we used multielectrode body surface recordings to identify the drivers maintaining VF. Then, we analyzed electrograms in the driver regions using endocardial and epicardial catheter mapping during sinus rhythm. Established electrogram criteria were used to identify the presence of structural alterations. Results: VF occurred spontaneously in 3 patients and was induced in 16, whereas VF was noninducible in 5. VF mapping demonstrated reentrant and focal activities (87% versus 13%, respectively) in all. The activities were dominant in one ventricle in 9 patients, whereas they had biventricular distribution in others. During sinus rhythm areas of abnormal electrograms were identified in 15/24 patients (62.5%) revealing localized structural alterations: in the right ventricle in 11, the left ventricle in 1, and both in 3. They covered a limited surface (13±6 cm2) representing 5±3% of the total surface and were recorded predominantly on the epicardium. Seventy-six percent of these areas were colocated with VF drivers (P

SCOPUS: ar.j, info:eu-repo/semantics/published

Objectives: The study objectives were to evaluate the safety, effectiveness, and hemodynamic performance of a new stented bovine pericardial aortic valve. Methods: This trial enrolled patients with symptomatic moderate or severe aortic stenosis or chronic, severe aortic regurgitation. We assessed death, valve-related adverse events, functional recovery, and hemodynamic performance at discharge, 3 to 6 months, and 1 year, as required by the US Food and Drug Administration for regulatory approval. The primary analysis compared late linearized rates of valve-related adverse events after implantation with Food and Drug Administration–specified objective performance criteria to determine whether the adverse event rates associated with the valve are within acceptable limits. Adverse events included thromboembolism, thrombosis, all and major hemorrhage, all and major paravalvular leak, and endocarditis. Results: The primary analysis included 864 patients who received an implant and 904.1 valve-years of follow-up. A total of 577 patients completed the 1-year evaluation. The primary end point was met for death, thromboembolism, thrombosis, all and major paravalvular leak, and endocarditis, but not for all and major hemorrhage. At 1 year, freedom from all death and from valve-related death was 96.4% and 99.7%, respectively. From baseline to 1 year, New York Heart Association class changed as follows: I, 10.8% to 73.7%; II, 48.9% to 22.6%; III, 38.0% to 3.5%; and IV, 2.3% to 0.2%. Effective orifice area increased from 0.9 ± 0.5 to 1.5 ± 0.4 (P

Little is presently known about the outcome of atrial lesions performed with high-intensity focused ultrasound (HIFU) for atrial fibrillation ablation. We aimed to assess endocardial atrial lesions 6 months after epicardial HIFU ablation (Epicor™) and to evaluate the benefit of a combined ablation approach. Thirty patients (21 males, mean age 68 ± 12 years old) undergoing HIFU atrial fibrillation ablation during cardiac surgery were enrolled. Electrophysiological study (EPS) was performed 6 months after HIFU ablation, and endovascular radiofrequency was delivered in case of conduction gaps. Patients were followed up for at least 6 months after the EPS. At EPS, ten patients (38 %) had achieved complete or near-complete “box” isolation and four (15 %) had no visible lesion. Using this technology, freedom from symptomatic atrial arrhythmia at 6 months was 60 % (n = 18/30) (64 % for paroxysmal and 56 % for persistent subgroups) improving to 81 % (n = 21/26) (90 % for paroxysmal and 73 % for persistent subgroups) at 12 months after a facultative percutaneous endocardial approach was performed. Using an UltraCinch device sized below 10 improved the rate of complete lesion as assessed 6 months after surgery (58 % of complete or near-complete box isolation with UltraCinch device

The incidence of congenital atrioventricular (AV) block is between 1 in 15,000 and 1 in 20,000 births. It may occur in isolation or as a consequence of anomalous development of the conduction tissue in the context of a cardiac malformation. In this review, we use the term congenital AV bock to describe complete heart block when it is diagnosed in utero or at birth. The pathophysiological process is believed to be due to immune-mediated injury of the conduction system, which occurs as a result of transplacental passage of maternal anti-SSA/Ro-SSB/La antibodies. Many mothers are asymptomatic carriers, and less than one-third have a preexisting diagnosis of a rheumatological disorder. The AV block that develops months or years after birth probably occurs as a result of a different disease process that is poorly understood. The diagnosis of congenital AV block is usually confirmed by fetal echocardiography before birth and by electrocardiography after birth. The implantation of a pacemaker is recommended for symptomatic patients and for asymptomatic patients presenting with profound bradycardia, left ventricular dysfunction, a wide QRS interval, or a prolonged QT interval. It is now recognized that a subset of paced patients develop dilated cardiomyopathy and heart failure, and therefore regular follow-up is important. They are also at high risk of developing complications related to the presence of intracardiac material as a result of prolonged exposure to pacing materials. Future areas of research to minimize these risks include assessing the impact of alternative stimulation sites and the development of new cardiac stimulation techniques.

Objective: It has been reported that balloon aortic valvuloplasty immediately before transfemoral or transapical transcatheter aortic valve implantation has mostly little to no clinical value. We aimed to provide data on the need for balloon aortic valvuloplasty in patients undergoing transaortic transcatheter aortic valve implantation. Methods: Patients undergoing transaortic transcatheter aortic valve implantation with the Edwards SAPIEN XT (Nyon, Switzerland) or 3 transcatheter heart valve were prospectively included at 18 sites across Europe. In the present analysis, we compare the periprocedural and 30-day outcomes of patients undergoing conventional (thorn balloon aortic valvuloplasty) versus direct (-balloon aortic valvuloplasty) transaortic transcatheter aortic valve implantation. Results: Of the 300 patients enrolled, 222 underwent conventional and 78 underwent direct transaortic transcatheter aortic valve implantation. Peak and mean transvalvular gradients were improved in both groups with no significant difference between groups. Procedural duration, contrast agent volume, and requirement for postdilation were also comparable. A trend toward fewer periprocedural complications was evident in the direct group (3.9% vs 11.3%; P = .053), with significantly lower rates of permanent pacemaker implantation (0% vs 5.0%; P = .034). Balloon aortic valvuloplasty omission had no significant effect on any of the 30-day safety and efficacy outcomes, including Valve Academic Research Consortium-2 composite end points (early safety events: 22.7% vs 17.4%, odds ratio, 1.17, 95% confidence interval, 0.53-2.62; clinical efficacy events: 20.5% vs 18.7%, odds ratio, 1.14, 95% confidence interval, 0.51-2.55). Conclusions: For many patients, balloon aortic valvuloplasty predilation seems to have little clinical value in transaortic transcatheter aortic valve implantation using a balloon expandable transcatheter valve and may result in a higher rate of periprocedural complications, particularly in terms of permanent pacemaker implantation.

Objectives Transaortic transcatheter aortic valve implantation (TAo-TAVI) is a recently developed alternative to transapical (TA) or transfemoral (TF) TAVI. We aimed to analyse the effectiveness and safety of TAo-TAVI as a first line approach and to compare it to patients receiving TAo-TAVI as a last resort, which is current practice. Methods ROUTE is a prospective, multicentre registry to assess the clinical outcomes of TAo-TAVI. Patients without contraindications for TA- and TF-TAVI (TAo-first) were compared to patients with contraindications for both of these access routes (TAo-last). Outcome analysis was based on VARC II defined clinical end-points. Results Three hundred and one patients were included, of which 224 patients met TAo-first and 77 TAo-last criteria. The valve was delivered and catheter retrieved successfully in all patients. In the TAo-first group, rates of conversion to open surgery and requirement for a second valve were low and not different compared to TAo-last patients (1% vs. 3%, P = 0.46 and 1% vs. 3%, P = 0.46, respectively). This was also true for the rate of paravalvular regurgitation (≥ moderate: 4% vs. 3%). All-cause mortality at 30-days was 6% vs. 5% ( P = 0.76), rates of stroke 2% vs. 0% ( P = 0.24), pacemaker implantation (11% vs. 4%, P = 0.093), and life-threatening bleeding 4% vs. 3% ( P = 0.70). Valve safety (both 85%, P = 0.98) and clinical efficacy (80% vs. 82%; P = 0.73) did not differ between groups. Conclusions Although comparative data to TA and TF procedures were not available in the present analysis, findings suggest that TAo may be considered not only as a last resort strategy when classical access routes are deemed unfeasible, but also as a potential first-line option, with only low rates of paravalvular regurgitation and permanent pacemaker implantation. Clinicaltrials.gov NCT01991431.

Introduction: Patients who have undergone repair of Tetralogy of Fallot (TOF) often present with right bundle branch block. Cardiac resynchronization therapy (CRT) with right ventricular (RV) or biventricular (BiV) stimulation has been proposed as a modality to correct electrical abnormalities and improve cardiac contractility in patients with repaired TOF. We aimed to 1) compare ventricular electrical activation in adults with repaired TOF during RV versus BiV stimulation, using a non-invasive epicardial mapping system, and 2) examine the clinical mid-term effects of BiV resynchronization. Methods: 9 adults with repaired TOF were implanted with a CRT system and underwent 1) a non-invasive epicardial mapping (n = 9) during sinus intrinsic rhythm, RV and BiV pacing 2) a clinical evaluation (n = 7) before and after 6 months CRT with assessment of NYHA class and exercise capacity. Results: During intrinsic rhythm, non-invasive mapping demonstrated delayed activation of the right compared with the left ventricle in all patients, with the greatest activation delay noted near the infundibulum. However, we observed important differences among patients, in the severity of activation delays. Global activation time and an index of dyssynchrony were improved (p < 0.05) during BiV pacing compared with RV pacing and spontaneous rhythm. BiV pacing increased (p < 0.05) exercise tolerance and lowered the mean NYHA functional class at 6 months of follow up. Conclusion: Patients with corrected TOF present with different patterns of ventricular activation. RV stimulation modestly improved RV activation sequence and was associated with a delayed LV activation. Biventricular stimulation significantly decreased right and left ventricular dyssynchrony. © 2011 Elsevier Ireland Ltd.

International audience; OBJECTIVES The Registry of the Utilization of the TAo-TAVR approach using the Edwards SAPIEN Valve (ROUTE) was established to assess the effectiveness and safety of the use of transaortic (TAo) access for transcatheter aortic valve replacement (TAVR) procedures (NCT01991431). BACKGROUND TAVR represents an alternative to surgical valve replacement in high-risk patients. Whereas the transfemoral access route is used commonly as the first-line approach, transapical access is an option for patients not suitable for transfemoral treatment mainly due to anatomic conditions. TAo-TAVR has been shown to be a viable alternative surgical access route; however, only limited data on its effectiveness and safety has been published. METHODS ROUTE is a multicenter, international, prospective, observational registry; data were collected from 18 centers across Europe starting in February 2013. Patients having severe calcific aortic stenosis were documented if they were scheduled to undergo TAo-TAVR using an Edwards SAPIEN XT or a SAPIEN 3 valve. The primary endpoint was 30-day mortality. Secondary endpoints were intraprocedural or in hospital and 30-day complication rates. RESULTS A total of 301 patients with a mean age of 81.7 +/- 5.9 years and an Society of Thoracic Surgeons score of 9.0 +/- 7.6% were included. Valve success was documented in 96.7%. The 30-day mortality was 6.1% (18/293) (procedure-related mortality: 3.1%; 9 of 293). The Valve Academic Research Consortium-2 defined complications included myocardial infarction (1.0%), stroke (1.0%), transient ischemic attack (0.3%), major vascular complications (3.4%), life-threatening bleeding (3.4%), and acute kidney injury (9.5%). In 3.3% of patients, paravalvular regurgitation was classified as moderate or severe (10 of 300). Twenty-six patients (8.8%) required permanent pacemaker implantation. CONCLUSIONS TAo access for TAVR seems to be a safe alternative to the transapical procedure. (C) 2016 by the American College of Cardiology Foundation.

Background In the past 5years a few number of studies and case reports have come out focusing on biventricular (BiV) stimulation for treatment of congenital heart disease related ventricular dysfunction. The few available studies include a diverse group of pathophysiological entities ranging from a previously repaired tetralogy of Fallot (TOF) to a functional single ventricle anatomy. Patient's status is too heterogeneous to build important prospective study. To well understand the implication of prolonged electromechanical dyssynchrony we performed a chronic animal model that mimics essential parameters of postoperative TOF. Methods Significant pulmonary regurgitation, mild stenosis, as well as right ventricular outflow tract (RVOT) scars were induced in 15 piglets to mimic repaired TOF. 4months after hemodynamics and dyssynchrony parameters were compared with a control group and with a population of symptomatic adult with repaired TOF. Results Comparing the animal model with the animal control group on echocardiography, RV dilatation, RV and LV dysfunction, broad QRS complex and dyssynchrony were observed on the animal model piglets. Moreover, epicardial electrical mapping showed activation consistent with a right bundle branch block. The animal models displayed the same pathophysiological parameters as the post TOF repair patients in terms of QRS duration, pulmonary regurgitation biventricular dysfunction and dyssynchrony. Conclusion This chronic swine model mimics electromechanical ventricular activation delay, RV and LV dysfunction, as in adult population of repair TOF. It does appear to be a very useful and interesting model to study the implication of dyssynchrony and the interest of resynchronization therapy in TOF failing ventricle.

A new technique described as Less Invasive Ventricular Enhancement (LIVE) was performed to reduce volume and reshape the left ventricle without cardiopulmonary bypass in post-myocardial infraction, ischemic cardiomyopathy heart failure patients. Access in the early stages was via median sternotomy

Introduction We recently found the presence of a pro-arrhythmic electrophysiological substrate with increased collagen content and slow conduction in the healthy right ventricular outflow tract (RVOT). An epicardial layer of fat is commonly found in the RVOT but whether fat penetrates in the myocardium and regulates RVOT structure and electrophysiology remains unknown. Objective To assess the presence and localization of fat infiltrations (FI) in the healthy RVOT. Methods The presence of FI was assessed histologically in Masson's trichrome and Oil-Red-O stained sections from young healthy pigs (n = 4) and human donor hearts with no cardiac disease history (n = 5). High resolution MRI (9.4 T Bruker Biospin) was used to localize fat in formaldehyde-fixed human RVOTs. The expression of selected targets was assessed by qPCR and Western Blot in the subepicardial layer (EPI) of the RV free wall (RVFW) and RVOT of healthy pigs. Results Sporadic FIs could be observed in the pig RVOT but were absent in the RVFW. In human hearts, FIs were present in the RVFW, LV free wall but were larger in the RVOT. High resolution MRI showed the presence of 3 layers in the human RVOT wall with a thick epicardial fat layer, a transition layer composed of myocardial fibers and fat (up to 50% of wall thickness) and a muscular endocardial layer. Intramyocardial fat content increased with age. The mRNA expression of perilipin (PLIN1) and the adipogenic hormone adiponectin (ADIPOQ) was significantly higher in the RVOT EPI compared to the RVFW (P Conclusion FIs are in direct contact with the adjacent myocardium in the healthy porcine and human RVOT. Activin-A is likely to contribute to the higher collagen content found in the healthy RVOT as observed in the atria. Thus, these infiltrations are likely to participate to RVOT slower conduction and arrhythmogenesis.

Background The recent development of accurate methods to measure two-dimensional strain during dobutamine stress echocardiography has reactivated the debate as to the respective value of myocardial perfusion versus myocardial function assessment in detecting coronary stenoses. The aim of our study was to compare the effects of progressive coronary constrictions on two-dimensional strain and myocardial contrast echocardiography parameters during stress conditions. Methods Nine open-chest pigs were studied in the setting of various degrees of coronary constrictions. Two-dimensional strain and myocardial contrast echocardiography with Flash refilling sequence acquisitions were obtained at rest and during dobutamine infusion. Values of longitudinal strain (LS), circumferential strain (CS), radial strain (RS), and wall thickening, as well as myocardial perfusion parameter (A.b), were then calculated. Results At rest, accuracy for detecting coronary stenosis was higher for CS, LS, and A.b (74%, 67%, and 69%, respectively) than for RS or wall thickening (62% and 64%, respectively). Dobutamine stress echocardiography increased the accuracy of A.b and LS to 77% and to 73%, respectively. Sensitivity during stress was higher for CS (93%) and A.b (77%), whereas specificity was higher for LS (89%) than for other parameters. Combined evaluations (CS+A.b, CS+LS, and LS+A.b) during dobutamine stress echocardiography improved both sensitivity and accuracy for detecting coronary stenosis. Conclusion Quantitative evaluation of contraction by LS and CS analysis and perfusion (A.b) during stress echocardiography resulted in similar accuracy levels, whereas the radial component was less accurate. Maximal sensitivities and accuracies were obtained by combined evaluations during stress.

ObjectivesThe aim of this study was to assess and validate 2-dimensional (2D) strain for the detection of ischemia during dobutamine stress echocardiography (DSE).BackgroundEvaluation of abnormalities of left ventricular (LV) function from wall thickening during DSE is unsatisfactory and requires a high level of expertise.MethodsIn 10 open-chest anesthetized pigs, myocardial deformation was studied before and during dobutamine infusion, under control and ischemic conditions produced by various degrees of coronary artery constriction: 2 of nonflow-limiting stenoses (NFLS) of increasing severity reducing left anterior descending artery hyperemic flow by 40% and 70% and 2 flow-limiting stenoses (FLS) reducing resting coronary flow by 25% and 50%. Agreement between 2D strain echocardiography and sonomicrometry (reference method) was evaluated by linear regression and Bland-Altman analysis.ResultsGood correlation and agreement were observed between 2-dimensional strain and sonomicrometry at rest and during dobutamine infusion; longitudinal strain: r = 0.77, p < 0.001 and r = 0.80, p < 0.001; radial strain: r = 0.57, p < 0.05 and r = 0.63, p < 0.05; and circumferential strain: r = 0.74, p < 0.001 and r = 0.58, p < 0.001. Circumferential and longitudinal strains in the risk area were significantly decreased at rest in the presence of FLS and during dobutamine infusion in the presence of NFLS. By contrast, radial strain was significantly decreased in the presence of severe FLS only during dobutamine infusion.ConclusionsThe 2D strain provides accurate assessment of LV regional function. Evaluation of circumferential and longitudinal strains during DSE has real potential for quantitative evaluation of LV deformation in the routine assessment of ischemia.

Aims Left ventricular (LV) lead implantation through the coronary sinus (CS) can be limited and sometimes not possible—alternative approaches are needed. Minimally invasive, robotically guided LV lead implantation has major advantages, but there are little published data about the short- and long-term follow-ups, in terms of feasibility, safety, electrical performance, and impact on clinical outcome. Methods and results A total of 21 heart failure patients underwent robotically guided LV lead implantation using the Da Vinci Robotic System. Indications were failed implant with conventional approach through the CS ( n = 16) and non-response to conventional cardiac resynchronization therapy ( n = 5). During the procedure, the entire LV free wall was exposed through 3 transthoracic ports (10 mm diameter each) allowing ample choice of stimulation site and the ability to implant 2 LV leads via a Y connector. Patients were prospectively followed up for 1 year. The two LV leads were successfully implanted in all patients. No peri-procedural complications were observed. After a mean stay in the intensive care unit of 1.2 ± 4 days, the 21 patients were hospitalized in the EP department for 6.7 ± 2.9 days. Acute LV thresholds were excellent (1.0 V ± 0.6/0.4 ms) and stayed stable at 1-year follow-up (1.5 V ± 0.6/0.4 ms, P = 0.21). Four patients demonstrated an increased threshold (>2 V/0.4 ms). There was no phrenic nerve stimulation. After 12 months, in the failed implant group, 69% of the patients were echocardiographic and clinical responders. Conclusion The robotic approach was feasible, safe, and minimally invasive. Accordingly, robotically guided LV lead implantation seems to offer a new alternative when conventional approaches are not suitable.

Objective: Coronary artery disease is the main cause of mortality and morbidity in patients on renal therapy replacement. The aim of this study was to define peri-operative risk and long term results of coronary artery bypass grafts (CABG) in dialysis patients. Methods: this retrospective study included 82 patients in chronic dialysis who underwent CABG between 1978 and 1997. The mean age was 61 ^ 10 years (range 28‐81 years), 84% of the patients were male and the average duration of dialysis was 57 months (range 1‐148 months). Combined procedures were carotid endarterectomy in one case, left ventricular aneurysm resection in one and valvular replacement in 10 (nine aortic and one mitral replacements). The operation was elective in 42 patients (51%) and urgent in the others. Previous myocardial infarction was found in 37 patients (45%) and left ventricular ejection fraction (LVEF) at less than 45% in 15 patients (18%); 23 patients (28%) were in NYHA class III or IV and regarding angina functional status, 77% in CCS class 3 or 4. Follow-up was complete. Statistical analysis included 30 and pre and peri-operative data. Statistical analysis used Chi-square analysis or Fisher’s exact test, and the Mann‐Whitney test when appropriate. The estimated probability of survival, including postoperative mortality, was calculated by the method of Kaplan‐Meyer, and the Log-Rank test used to compare the results. Results: the hospital mortality was 14.6 % (na 12). Ischemic time and ECC time were significantly lengthened in dead patients (Pa 0:01). Moreover, use of internal mammary artery was directly related to lower hospital mortality (Pa 0:02). For previous myocardial infarction, LVEF at less than 45%, diabetes and combined procedure, a P-value of # 0.1 was calculated. The follow-up ranged from 1 to 140 months (mean 36 months). There were 39 late deaths. The survival rates (included hospital mortality) were 71^5%, 56^6% and 39^6% at 1, 3 and 5 years, respectively. All surviving patients improved their functional status and had symptomatic relief. Statistical analysis showed significant difference in favor of long term survival for patients younger than 60 years, LVEF . 45% and NYHA class I or II. Conclusion: these data confirm that CABG in patients with renal replacement therapy is associated with an high operative and long term mortality. However it allows an improvement of functional status, and so, let possible duration of dialysis. It may be expected that more active prevention and detection of coronary disease might improve these results. q 1999 Elsevier Science B.V. All rights reserved.

A key element to the success of aortic valve reimplantation (David's procedure) is the position of the aortic annulus in the Dacron tube (DuPont, Wilmington, DE). The variable level of the right ventricular insertion can cause technical difficulties, especially when the right ventricular insertion occurs above the aortic annulus. To resolve this issue, a technical adjunct is described using a right superior ventriculotomy. This technique allows perfect aortic annulus containment, avoids any rocking motion of the margin of the right coronary cusp, and affords the procedure better long-term durability.

Repair of post-infarction ventricular septal defect (VSD) remains a challenging procedure with a high risk of VSD recurrence. In order to reduce this risk, a double patch and glue technique was introduced in the department in 1986. This surgical technique is hereunder presented. Since 1971, ninety-three patients have been operated on early (≪15 days) after the occurrence of a post-infarction VSD. This retrospective study allows to compare the results of this double patch and glue technique to those obtained with the conventional one, in terms of hospital death and VSD recurrence. The double patch and glue technique avoids recurrence of VSD and plays a part in reducing hospital mortality.

Management of carotid or coronary lesions associated with abdominal aortic aneurysm (AAA) remains controversial. To determine the influence of these lesions on the outcome of elective infrarenal AAA repair, we review our experience between January 1978 and December 1992. A total of 345 consecutive patients underwent infrarenal AAA repair. Procedures were performed under emergency conditions in 62 patients (18%) and electively in 283 patients (82%). Carotid and coronary risk was assessed in all 283 patients undergoing elective operations. There were 259 men (91.5%) with a mean age of 68 years (range: 45-88 years) and 24 women (8.5%) with a mean age of 76 years (range: 59–92 years). Previous cardiac manifestations included myocardial infarction in 57 patients (20%), angina in 50 patients (17.6%), coronary bypass grafting in 14 patients (14.9%), and coronary transluminal angioplasty in two patients. Cerebral ischemic attacks had been observed in 11 patients (3.8%) including transient events in two cases. Carotid endarterectomy had been performed in two patients. Assessment of carotid artery risk using Doppler ultrasonography led to selective carotid angiography in six patients and carotid endarterectomy in two patients. Assessment of coronary risk using a cardiac stress test was performed in 204 patients. Results were normal or subnormal in 132 patients (46.6%), abnormal in 21 patients (7.4%), and uninterpretable in 51 patients (18%). Coronary arteriography was performed in 151 patients (53.3%) for secondary assessment after the cardiac stress testing in 72 patients (25%) and for primary assessment in 79 patients (27.9%). Significant coronary lesions were demonstrated in 52 patients (18% of the overall population; 34% of coronary arteriography procedures). In 12 cases the lesions were not considered as threatening. In four cases the lesions were deemed inoperable. In the remaining 36 cases the lesions were treated either by aortocoronary bypass grafting (34 cases) or percutaneous transluminal angioplasty (two cases). In 11 of the 36 treated cases the patient was asymptomatic and had no history of coronary disease. In all cases AAA was treated by resection graft. Eight patients (2.8 ± 1%) died during hospitalization including two deaths related to preexisting cardiac insufficiency. No death was attributed to preoperative work-up or treatment of associated lesions. With a mean follow-up of 62 months (range: 1–14 years), late mortality involved 96 patients (33.9 ± 3%) including 16 deaths due to cardiac causes (16.7 ± 4%) and 10 due to stroke (10.4 ± 3%). Actuarial survival including deaths during hospitalization was 70.5 ± 3% at 5 years and 41.4 ± 5% at 10 years. Comparison of these results with those previously reported supports our policy of performing carotid or coronary angiography in patients selected by noninvasive tests. (Ann Vasc Surg 1997;11:467–472.)

Background The investigation of single cardiac myocytes from healthy and diseased hearts of various species is a valuable tool to explore cardiac physio/ pathophysiology. The application of cell isolation to human donor tissue has been proofed to be difficult due to the limited amount of human tissue (mainly human right atrial appendages during cardiac surgery). Another limitation is the low viability of cardiomyocytes after isolation. In this study, we present a method to obtain single cardiac myocytes from different regions of human heart. Methods and results Human hearts rejected for transplantation were obtained from Bordeaux hospital. This protocol was approved by the Agence de la Biomedecine. Left atrial (LA) and ventricular (LV) myocytes were obtained by enzymatic dissociation. The ventricles and right atrium were removed and used for other studies (e.g. high resolution optical mapping). LA was cannulated by the circumflex artery and mounted into a Langendorff perfusion system after suture of the leaky atrial branches. LA was perfused with a Ca2+-free solution (~10 min), then collagenase and protease solution (0.08 mM Ca2+) and recirculated for ~25 min. Enzymes were washed out with a 0.2 mM Ca2+ solution. LA was separated into 4 regions: Endocardium, Epicardium, roof and pulmonary vein; LV myocytes were also obtained. Cells were re-suspended into a 1.8 mM Ca2+ solution by steps. Ca2+ transients were recorded (Fura-2, field stimulation) using an IonOptix system and cell membrane was stained with di-8 ANEPPS and visualized under confocal microscopy. Ca2+ tolerant myocytes were obtained from the 4 LA regions and LV. Human cardiac myocytes respond to electrical stimulation and Ca2+ transient can be recorded. Analysis of functional and structural data will be presented. Conclusion Isolation of single cardiac myocytes from human samples is a tedious task, but we present data showing reliable method to obtain functional and structural insights. The author hereby declares no conflict of interest

Left ventricular dilatation following anterior acute myocardial infarction is associated with increased mortality and hospitalization for heart failure. Left volume reduction surgery for ischemic cardiomyopathy has lost favor due to the invasive nature of the procedure and the need for

PEA Recorded in the Atrium. Introduction: Preliminary studies have revealed a high correlation between peak endocardial acceleration (PEA) measured with a sensor embedded in a ventricular lead and human cardiac contractility. In this study we assessed (1) the contributions made by measurements of PEA1, an index of ventricular systolic contraction, from the right atrium, and (2) the feasibility of recording a fourth component of PEA (PEA4), coincident with atrial contraction and corresponding to the phonocardiographic fourth heart sound. Methods: We placed a PEA sensor embedded at the tip of a right atrial lead in 9 pigs. A 7F Millar catheter tip micromanometer was introduced into the left ventricular (LV) cavity to measure dP/dtmax. Myocardial contractility was increased by infusion of dobutamine and depressed by the infusion of esmolol. We searched, during VDD pacing, for PEA4 following atrial systole, while gradually lengthening the atrioventricular delay. Ventricular fibrillation was then triggered by rapid stimulation. Results: The changes in PEA1 were correlated with the changes in LV dP/dtmax (r = 0.91; P < 0.001). A low-frequency component of the endocardial signal (PEA4) was visible approximately 50 milliseconds after the atrial electrogram in all experiments. Following the induction of ventricular fibrillation, PEA4 remained visible on the endocardial recording, simultaneous with the sensed atrial electrogram. Conclusions: This study confirms the merit of embedding a PEA sensor in an atrial lead. The exploitation of the information provided by the PEA1 signal remains pertinent and the possibility to record an additional PEA4 component offers the perspective of new clinical applications. (J Cardiovasc Electrophysiol, Vol. 22, pp. 579-583 May 2011)

Optimal treatment of right ventricular (RV) dysfunction observed in patients after tetralogy of Fallot (TOF) repair is unclear. Studies of biventricular (BiV) stimulation in patients with congenital heart disease have been retrospective or have included patients with heterogeneous disorders.The purpose of this study was to determine the effects on cardiac function of stimulating at various cardiac sites in an animal model of RV dysfunction and dyssynchrony and in eight symptomatic adults with repaired TOF.Pulmonary stenosis and regurgitation as well as RV scars were induced in 15 piglets to mimic repaired TOF. The hemodynamic effects of various configurations of RV and BiV stimulation were compared with sinus rhythm (SR) 4 months after surgery. In eight adults with repaired TOF, RV and left ventricular (LV) dP/dt(max) were measured invasively during SR, apical RV stimulation, and BiV stimulation.At 4 months, RV dilation, dysfunction, and dyssynchrony were present in all piglets. RV stimulation caused a decrease in LV function but no change in RV function. In contrast, BiV stimulation significantly improved LV and RV function (P.05). Echocardiography and epicardial electrical mapping showed activation consistent with right bundle branch block during SR and marked resynchronization during BiV stimulation. In patients with repaired TOF, BiV stimulation increased significantly RV and LV dP/dt(max) (P.05).In this swine model of RV dysfunction and in adults with repaired TOF, BiV stimulation significantly improved RV and LV function by alleviating electromechanical dyssynchrony.

Introduction: The peak of endocardial acceleration (PEA) is an index of myocardial contractility. We aimed to (1) demonstrate that the PEA measured by the noninvasive cutaneous precordial application of an accelerometer sensor is related to left ventricular (LV) dP/dt max and (2) assess the usefulness of PEA monitoring during graded ischemia and during different configurations of sequential biventricular pacing. Methods and Results: Measurements of invasive LV dP/dt max were compared with measurements of transcutaneous PEA in seven pigs at baseline and during acute drug infusions; increased heart rate; right, left, biventricular and sequential biventricular pacing before and after graded ischemia induced by the constriction of the left anterior descending coronary artery. A consistent PEA signal was obtained in all animals. PEA changes were highly related to LV dP/dt max changes (r= 0.93; P < 0.001). The changes of LV contractility induced by the different pacing configurations were detected by PEA analysis in the absence of ischemia (r= 0.94; P < 0.001) and in the presence of ischemic LV dysfunction (r= 0.91; P < 0.001). Conclusion: Noninvasive PEA measurement allows monitoring of left ventricular contractility and may be a useful tool to detect global effect of ventricular ischemia and to optimize the choice of both pacing site and pacing configuration.

Aims In post-operative setting after cardiac surgery, the choice of the optimal ventricular pacing site remains an issue, particularly in patients with ischaemic cardiomyopathy. We aimed to investigate the impact of the left ventricular (LV) pacing site in an animal model of incremental myocardial ischaemia. Methods and results Three epicardial LV pacing leads were implanted in 10 pigs [LV1 in the territory of the left anterior descending (LAD) artery, LV2 in the lateral border of this territory, LV3 in an anatomically opposed position]. A two-dimensional strain echocardiogram was performed at baseline and during two levels of incremental ischaemia, corresponding to 30 and 70% reduction of coronary flow in the LAD, during spontaneous sinus rhythm (SR) and during LV1, LV2, LV3, and multi-LV (LV1 + LV2 + LV3) pacing. At baseline ( n = 10), LV + d P /d t max was decreased ( P < 0.01) during LV1, LV2, LV3, and multi-LV pacing compared with SR. At first level of ischaemia ( n = 7; 3 animals died from ventricular fibrillation), LV1 pacing (ischaemic area) induced a significant decrease in LV + d P /d t max compared with SR, LV2, LV3, and multi-LV pacing ( P < 0.05). At second level of ischaemia ( n = 6), LV1 pacing induced a significant decrease in LV + d P /d t max associated with an increase in the extent of myocardium with echocardiographic post-systolic shortening compared with SR, LV2, LV3, or multi-LV pacing ( P < 0.05). In contrast, multi-LV pacing induced a significant haemodynamic improvement compared with SR, LV1, LV2, and LV3 ( P < 0.05). Conclusions Pacing within an ischaemic area has detrimental impact on acute global and regional LV function. More studies are needed to assess the impact of multi-LV pacing in chronic ischaemic conditions.

Cardiac support device implantation is a new and promising therapy for refractory heart failure. If functional and echocardiographic modifications have largely been reported following this procedure, there is a paucity of information in the clinical setting about cellular abnormalities modifications during the 'reverse remodeling' process. We report for the first time a clinical measurement of cardiac sympathetic function using 123I-MIBG scintigraphy following cardiac support device implantation.

BACKGROUND: Despite major improvement in surgical techniques and intensive care management, stroke remains one of the most devastating complications of coronary artery bypass grafting (CABG). We aimed to determine factors predicting the occurrence of stroke during CABG. A special interest was focused on preoperative therapies. METHODS: We prospectively enrolled 810 consecutive candidates for CABG alone in a specific database, including all pre- and perioperative data (history, clinical, therapeutic, cardiac catheterization, surgical and intensive care data). Univariate tests and then multiple logistic regression analysis were used to determine independent predictive factors. RESULTS: During the first postoperative month, stroke occurred in 11 cases and transient ischemic attack (TIA) in 4 additive cases (cumulative rate: 1.85%). After the multivariate analysis, the following factors remained significant (p