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UNLABELLED The SmarTracking (ST) algorithm (Marathon 294-09, Intermedics Inc.) uses the sensor-calculated rate (SCR) to define a "variation band" for the intrinsic sinus rate. If the sinus rate exceeds the upper limit of the band, the ventricular pacing rate is limited by the ST rate (STR) and Wenckebach behavior is observed. The present study was aimed at evaluating the behavior of the ST mechanism in patients with healthy sinus node, during exercise and at rest. METHODS Twenty-one patients (15 men; mean age 67.8 +/- 9.7 years) with normal sinus function were studied. Heart rate was recorded via the rate profile of the implanted pacemaker (Relay 294-03, Intermedics Inc.), and STR and SCR were obtained via a previously calibrated strap-on pacemaker. A 15-minute protocol was used during which subjects alternated periods of walking with periods of rest. RESULTS The relative difference between the average STR and the average sinus rate (DST) was calculated for each phase of the protocol as well as the maximum number of patients showing inappropriate Wenckebach behavior (#W). At nominal settings, DST was always positive and did not fall below 20%. #W was maximum at rest (5) and during heavy exercise (3). By increasing the STR at rest to 95 ppm and the maximum pacing rate to 150 ppm, the #W was reduced to zero for all types of activity except during very fast walk where #W was 1. CONCLUSION In general, there was no competition observed between the STR and the intrinsic rhythm. In some cases, the STR at rest and the maximum pacing rate had to be reprogrammed for optimal performance.

International audience; AIMS: Inappropriate therapy delivered by implantable cardioverter defibrillators (ICDs) remains a challenge. The OPERA registry measured the times to, and studied the determinants of, first appropriate (FAT) and inappropriate (FIT) therapies delivered by single-, dual- and triple-chamber [cardiac resynchronization therapy defibrillator (CRT-D)] ICD. METHODS AND RESULTS: We entered 636 patients (mean age = 62.0 ± 13.5 years; 88% men) in the registry, of whom 251 received single-, 238 dual-, and 147 triple-chamber ICD, for primary (30.5%) or secondary (69.5%) indications. We measured times to FAT and FIT as a function of multiple clinical characteristics, examined the effects of various algorithm components on the likelihood of FAT and FIT delivery, and searched for predictors of FAT and FIT. Over 22.8 ± 8.8 months of observation, 184 patients (28.9%) received FAT and 70 (11.0%) received FIT. Ventricular tachycardia (VT) was the trigger of 88% of FAT, and supraventricular tachycardia was the trigger of 91% of FIT. The median times to FIT (90 days; range 49-258) and FAT (171 days; 50-363) were similar. The rate of FAT was higher (P

T-wave alternans (TWA) is an accepted marker of risk for malignant ventricular arrhythmias, for which prognosis value has been established in different populations. Short QT syndrome (SQTS) is a very rare primary electrical disease carrying the risk of ventricular fibrillation. TWA in SQTS has not been evaluated yet.Thirteen patients with SQTS (QT = 308 ± 16 ms, QTc = 329 ± 10 ms, heart rate = 69 ± 8 beats/min) underwent microvolt TWA measurement using spectral analysis. TWA testing was performed using Heartwave II (Cambridge Heart™, Inc., Bedford, MA, USA) during bicycle exercice and classified as negative, positive, or indeterminate according to the published standards for clinical interpretation.Twelve patients were male (mean age 23 ± 5 years). Five were asymptomatic, three presented with aborted sudden cardiac death, and five with unexplained syncope. Six patients belonged to two unrelated families, while familial cases of SQTS were present for two other patients. A familial history of sudden death (SD) was present for seven patients. Ventricular fibrillation was inducible in three patients. Four patients were implanted with an implantable cardioverter-defibrillator and one presented with polymorphic ventricular tachycardia during follow-up. TWA was negative in each but one patient (indeterminate). Maximal negative heart rate was 118 ± 12 beats/min. Patients with previous SD displayed significant shorter QT and higher resting heart rate compared to the remaining cases.TWA testing is negative in 12 of 13 SQTS patients, even in the symptomatic or inducible ones. Measurement of TWA using conventional protocol and criteria for risk stratification in SQTS seems therefore useless.

We present the case of a patient with incessant slow-fast atrio-ventricular (AV) node reentrant tachycardia induced by dual AV node conduction with aborted conduction to the ventricles. The unapparent conduction over the slow pathway was suspected here because of spontaneous nodal echoes without QRS complexes occurring during sinus rhythm, manifested as isolated premature atrial beats and which repetitively induced the tachycardia.

Occurrence of supraventricular tachycardia is a common cause of clinical impairment for patients implanted with CRT devices. We report the case of atrial activity oversensing by the left ventricular (LV) lead during typical flutter, which led to LV pacing inhibition. Temporary reprogramming of the LV detection from standard bipolar to extended bipolar and cavotricuspid isthmus ablation solved this problem.

Introduction T wave alternans (TWA) is a reliable marker of risk for malignant ventricular arrhythmias whose prognosis value has been established in many populations. Short QT syndrome (SQTS) is a recently described and very rare channelopathy defined by a decrease in repolarisation duration and carrying a risk of ventricular fibrillation. TWA in SQTS has not been evaluated at yet. Methods 6 patients with SQTS (QT 310 ± 16 ms, QTc 329 ± 11 ms) underwent microvolt TWA measurement using spectral analysis. TWA testing was performed using Heartwave II (Cambridge HeartTM) during bicycle exercice and classified as negative, positive or indeterminate according to the published standards for clinical interpretation. Results there were 6 men (mean age 24 ± 2 yo): 4 asymptomatic, 1 with previous sudden cardiac death and 1 with unexplained syncope. 3 patients belonged from the same family. Familial history of SQTS was present in 4 (2 families) and history of unexplained sudden death was found in both families. Ventricular fibrillation was induced in 2 of 5 investigated patients. Two patients were implanted with an ICD without any appropriate therapy during follow-up. No patient was on any medical therapy. Genetic analysis was pending in each but without result at yet. TWA was negative in each patient except in one inducible asymptomatic patient (indeterminate due to too fast heart rate). Maximal negative heart rate was 113 ± 5 bpm. Conclusions Conversely to what is observed in other settings, TWA testing is negative in most SQTS patients even in the symptomatic or inducible ones. This may be explained by the longer diastolic interval according to the restitution curve theory. Measurement of TWA for risk stratification in SQTS is therefore useless.

PurposeThe infections after cardiac device implantation (CDI) are not well known in the real life because of the multiplicity of the circumstances. This is a monocentric prospective study.Method304 consecutive pts had a CDI in 6 months (feb to aug 2009): male 69% age 70±15 yo. The data of the pts were consecutively collected:type of device (VVI PM 10%, DDD PM 42%, CRT P 7%, VVI ICD 13%, DDD ICD 10%, CRT D 17%) (Primo Implant 73%, Device Replacement 21%, Lead Replacement 8%, Burying 2.3%).components of the NNIS score (N1. Nosocomial Infection Surveillance): −1 duration of the procedure (83±40mn); 7minus;2 ASA score (Am. Soc. Anesth)(asal=4%, asa2=22%, asa3=43%, asa4=30%, asa5=0); −3 surgical site Infection (SSI) Class: Clean wound 73%, fever the days before 6%.the prevention with antibiotic therapy was: – conventional: Cefuroxine 1.5 g 30 mn before and 0.75g each 2hr (93%; 69% timing conformity); – Vancomicyne 1gr 1hr before (3%); previous adjusted therapy (4%).the follow-up was of 3 months.Results7 SSI occurred at 43±36 days (2.3%) for DDD PM = 5, VVI ICD = 1, CRT D = 1. They were 2 endocarditis (for 2 implantations on the other side after an extraction, with the same germ) sepsis = 1 (diabetes), loge infection = 4 (2 after burying). The 7 pts had an extraction of the device and the leads. The risk factors of SSI were anticoagulation (7/7; p

BackgroundICD is an effective treatment to prevent SCD but very long term follow-up is poorly known.MethodsWe retrospectively studied the 67 patients implanted with an ICD at the University Hospital of Toulouse between 1989 and 1999.ResultsCharacteristics of the population are (number of patients): males: 56, ischemic heart disease (IHD): 42, mean EF 42%, secondary prevention: 62, abdominal implantation: 30, dual chamber devices: 57. Data were complete for 58 patients (mean follow-up: 100 months +/− 103), nine patients were lost to follow up (mean 52 +/− 40 months). Survival rate (of the 58 patients) is respectively 93%, 71% and 48% at 1, 5 and 10 years. Cause of death was cardiac for 10 patients (7 terminal cardiac failures, 2 sudden cardiac deaths and 1 endocarditis), extra cardiac for 7 patients and unknown for 13.Independent factors of global mortality are: age (p = 0.038), IHD (p = 0.035), NYHA>2 (p = 0.0058), EF

Congenital abnormalities of the coronary sinus (CS) are rare but can be responsible for unsuccessful implantation of a cardiac resynchronization therapy device. We report the case of an ectopic drainage of the CS in the left atrium. A left ventricular lead was implanted by the transseptal route.

Scheduled and/or thoracic, abdominal surgeries increase the risk of respiratory postoperative complications. In patients with chronic respiratory failure, preoperative evaluation should be performed to evaluate respiratory function in aim to optimize perioperative management. Preoperative gas exchange abnormalities (hypoxemia or hypercapnia) are associated with respiratory postoperative complications. Respiratory physiotherapy and prophylactic non-invasive ventilation should be integrated in a global rehabilitation management for cardiothoracic or abdominal surgery procedures, which are at high risk of postoperative respiratory dysfunction. Stopping tobacco consummation should be benefit, but decease risk of postoperative complications is relevant only after a period for 6 to 8 weeks of cessation. Bronchodilatator aerosol therapy (beta-agonists and atropinics) and inhaled corticotherapy allow a rapid preparation for 24 to 48 h. Systematic preoperative antibiotherapy should not be recommended.

Introduction radio-frequency (RF) ablation of premature ventricular beats (PVB) has been only reported as isolated cases or in short series. Methods 34 successive pts (25 men, 53 ± 18 yo) underwent RF ablation of frequent or symptomatic isolated PVB at our institution from 2005 to 2009. Indication, technique and results were reported. Results 43 RF ablation of PVB was performed for post-ischemic electrical storm in 7 pts (6 men), for symptomatic PVB in 7 (3 men) and for suspected VPB-induced tachycardiomyopathy in 20 (16 men) with 1,2 procedure/pt. RF was performed in each case using pace mapping and activation mapping with conventional technique. RF ablation of PVB during intractable post-ischemic electrical storm was initially successful in each pt but fatal electrical storm recurred in 4 during the following days. PVB were targeted in the left septal Purkinje network. 10 procedures were performed in 7 pts for palpitations or syncope, leading to complete or partial clinical success in 6 (PVB reduction 9400 ± 12200 to 420 ± 610 /24h, NS). 25 procedures were performed for suspected VPB-induced tachycardiomyopathy in 20 pts leading to complete success in 9 pts and to significant decrease in VPB in 5 pts. Mean VPB/24h was 17800 ± 8600 before and 3410 ± 8150 after and 125 ± 230 at 11 ± 6 months follow-up (p=0,0005). EF increase from 41 ± 8 to 53 ± 7% (p Conclusions RF ablation of PVB may be indicated if highly symptomatic, for electrical storm or for suspected tachycardiomyopathy with good although imperfect success rate

IntroductionSustained ventricular tachycardia (VT) in structural heart disease (SHD) is usually an indication for ICD implantation. Whether successful RF ablation of VT in this setting could avoid the need of ICD implantation is unknown.MethodsWe report our initial experience of VT ablation in 27 successive non-implanted pts (22 men, 62±18 yo) presenting with sustained monomorphic VT and SHD. An ICD was not implanted either because of debilitating or end stage extra cardiac pathology, advanced age or because the VT was well tolerated and EF was preserved. Amiodarone failed to control VT in 33% and beta-blockers in 73%.Results33 procedures were performed (1.2/pt). Seventeen pts had ischemic heart disease, four had ARVD, 2 dilated cardiomyopathy, 1 congenital and three had non-categorized SHD. Mean EF was 44±13% (5 pts with EF < 0,35%). The end-point was elimination of post-systolic potentials by RF. VT was inducible in 71% with 1 to 4 different morphology (1.8±1). Acute success was defined by lack of any inducible monomorphic sustained VT and was achieved in 78%. The only complication was an arterial dissection managed with angioplasty. One patient died after 10 days due to intractable heart failure associated with relapse of electrical storm. Patients were discharged on beta-blockers and amiodarone was interrupted except when otherwise indicated. Mean follow-up was 13±9 months. Four patients died from non arrhythmic cardiac or non cardiac causes. There was one late sudden death in a patient with low EF (incomplete procedure due to ongoing vascular complication). VT recurred in 24% without compromise of the vital status. RF ablation was performed in again in 5 pts and VT further recurred in two. Final VT recurrence rate including redo precedures was 12%.ConclusionsRF ablation for VT occurring in pts with SHD without ICD appears relatively safe and efficient and may be considered in some cases when ICD therapy is not desired because of associated morbidity, advanced age or when VT is well tolerated and does not occur in the context of advanced heart disease.

Introduction T wave alternans (TWA) has been demonstrated as a strong predictor of mortality and ventricular arrhythmias. ICD-stored intracardiac electrograms (IEGM) present a unique opportunity for detecting temporal relationship between the occurrence of TWA and spontaneous arrhythmia. The aim of the ETWAS study was to assess the feasibility of detection of TWA preceding the onset of VT/VF in IEGM. Methods 56 implanted patients with St Jude medical ICDs (44 men, 63 ± 12 yo, mean EF 34 ± 15%) were prospectively enrolled and monitored for one year. Thirteen different T wave parameters were extracted from IEGM (T amplitude, T peak time, Bazett and Hodges corrected T peak time, T end time, T duration between baseline crossing and between points of maximal slopes, T peak to T end, maximal ascending and descending slopes, timing of points of maximal slopes and T wave area). Successive beat by beat differences in each parameter in recordings prior to VT/VF were compared to control recordings in the same pts. TWA was considered if beat by beat variations for at least one parameter was significantly higher than baseline with a p value Results 22 VT/VF episodes (24 ± 13 beats, 71 ± 17 bpm) and 13 baseline (25 ± 9 beats, 72 ± 18) (ns) were analyzed in 12 pts (1,8 episode/ pt). TWA was present before VT/VF onset in 13 episodes (7 pts) with 1 to 9 differing parameters (3 ± 2). Significant beat by beat differences before VT/VF onset were observed in amplitude, timing, slopes, area and duration of the T wave. Amplitude of the beat by beat variations was 3 to10 larger in episodes than in baseline. Paired and unpaired comparisons of the averaged values of beat by beat variations however did not reveal significant difference between baseline and episodes, except for T wave amplitude (0,07 +/– 0,006 vs 0,14 +/– 0,03 mV, p=0.03 paired and 0,04 unpaired). Conclusions Detection of TWA prior to VT/VF might be useful in predicting imminent arrhythmia occurrence. TWA can be detected before VT/VF onset in more than half of episodes using a simple time-domain technique and multiple T wave measurements. T wave amplitude seems the most discriminant parameter.

Incidence, characteristics and predictive factors of transient ST-segment changes after DC shock are poorly known.91 consecutive pts referred for external cardioversion of atrial fibrillation (AF) (61 men, 69±10 yo) were prospectively included. The presence of ST elevation or depression was assessed on 12 lead-ECG immediately after the first DC shock. Correlations with DC shock characteristics (monophasic/biphasic and energy), clinical variables, echocardiographic parameters, biological parameters, medications, anaesthetic drugs as well with morphological features were made.18 and 20 pts underwent 200 J or 300 J monophasic and 53 pts 200 J biphasic DC shocks. We found an incidence of 48% for ST-segment changes: 35% for ST elevation and 13% for ST depression. ST changes did not induce significant cardiac events or alter AF recurrences. ST changes were not related to energy but ST elevation was significantly more often induced by monophasic (76% vs 6%, p0.0001) and ST depression by biphasic DC shocks (26% vs 3%, p=0.01). Using multivariate analysis, independent predictors for ST elevation were the use of monophasic DC shocks, of propofol and increased CRP, while a low ejection fraction and use of biphasic DC shocks were independent predictors of ST depression.ST-segment changes after external cardioversion with DC shock are common, short living and do not carry clinical significance. They are related to the monophasic or biphasic configuration of DC shock, to the use of propofol, to the ejection fraction and to an increased CRP.

We report the case of a patient presenting with incessant monomorphic ventricular tachycardia resistant to antiarrhythmic drugs, and in whom usual percutaneous vascular or pericardial access to the left ventricle was hindered by mechanical aortic and mitral prosthetic valves. Because an epicardial location was suspected by electrocardiogram features and because access to the target area through the coronary sinus was not possible, we decided to perform a surgically based radiofrequency (RF) ablation. Catheter mapping of the epicardial surface through surgical left lateral thoracotomy in the operating room confirmed the epicardial location of the arrhythmogenic substrate and allowed successful RF ablation of the clinically incessant tachycardia. Combined surgical and electrophysiological approach should therefore be performed when RF ablation is needed in case of unadvisable, difficult, or failed nonsurgical percutaneous access.

Concealed retrograde activation of bundle branch has been often proposed for explaining the persistence of functional rate-dependent bundle-branch block, but direct proof of such a mechanism in man has rarely been demonstrated. We report intracardiac recordings compatible with a reversal of activation of the left basal interventricular septum during intermittent left bundle-branch block. In our case, however, retrograde activation into the left bundle-branch cannot be recordable, probably due to the concealment within the muscular septal activation, even if this may explain the perpetuation of bundle-branch block according to the linking phenomenon.

We report the histological evaluation of both endocardial and epicardial radiofrequency (RF) ablation lesions in the explanted heart of a patient presenting with nonischemic dilated cardiomyopathy complicated by recurrent electrical storms. In this case, chronic RF lesions were almost transmural at the endocardial side, while remaining only superficial at the epicardial aspect, possibly because of the insulating interposed epicardial fat layer.

Background and objectives: Unlike for intensive care unit and home mechanical ventilators, no study has evaluated the user-friendliness of the recently introduced new anaesthesia workstations. Methods: We performed a prospective study to evaluate the user-friendliness of four anaesthesia workstations, which were categorized into two groups: first-generation (Kion) and second-generation (Avance, Felix and Primus). Twenty users (12 nurse-anaesthetists and 8 anaesthesiologists) from three different anaesthesia departments at the same univeristy hospital participated in the study. The user-friendliness scale evaluated 10 criteria, including two design and monitoring criteria, four maintenance criteria and four ventilation use criteria. Each criterion was evaluated from 0 (poor) to 10 (excellent). Results: The mean score obtained for the first-generation workstation was lower than those obtained for the three second-generation workstations (P < 0.05). No significant differences in the overall user-friendliness score was observed for the three second-generation workstations. The first-generation workstation obtained a significantly lower score than the three second-generation workstations for the design criteria (P < 0.01). For the screen criteria, the highest score was obtained by Felix, which has the largest screen and associated characters. For the main maintenance criteria, Kion and Felix obtained the lowest scores. No significant differences between the four anaesthesia workstations were found for only three of the user-friendliness criteria (self-test, alarms and settings). Conclusions: Anaesthesia machines have benefited from considerable advances in design and technology. This novel user-friendliness scale revealed that the most recent workstations were more appreciated by users than the first-generation of anaesthesia workstations. This user-friendliness scale may help the anaesthetic staff to 'consensually' choose the future workstation for their anaesthesia department.

We describe a case presenting with ventricular tachycardia as the manifestation leading to the diagnosis of sarcoidosis. The ventricular tachyacardia's origin is correlated with granuloma localization on magnetic resonance imaging.

RF ablation of frequent premature ventricular contractions (PVC) has recently been shown to improve left ventricular (LV) systolic function and dimensions in a few patients, however mainly when they originated from the right ventricular outflow tract.RF ablation was performed at various ventricular locations in six consecutive patients with frequent, isolated PVC associated with idiopathic dilated cardiomyopathy (DCM). Baseline clinical status, PVC counts, LV ejection fraction (EF) and end-diastolic diameter (EDD) were recorded at baseline and at 6 months of follow-up.PVC ablation was performed in the right ventricle in four patients, the left ventricle in two patients. Before RF ablation, five patients were in New York Heart Association (NYHA) functional class I, and one patient was in class II. After RF ablation, the mean PVC count/24 h decreased from 17,717 +/- 7,100 to 268 +/- 366 (p = 0.006) while LVEF increased from 42 +/- 2.5% to 57 +/- 3% (p = 0.0001) and LVEDD decreased from 60.0 +/- 3.5 to 54.0 +/- 3.7 mm (p = 0.0009). The clinical status normalized with regression of palpitations and NYHA class.Elimination of frequent isolated PVC in patients with DCM with RF can normalize the clinical status and LV systolic function and dimensions, regardless of the morphology or origin of the PVC.

Introductionearly repolarization (ER) in Brugada or short QT syndrome is common and has been associated with a less favourable outcome. Even if apparently paradoxical, ER can also be seen in long QT (LQT) but prevalence and correlations to other variables are unknown.MethodsECG of 105 LQT patients (44 men, 36±21 yo) and 269 age and gender matched controls (135 men, 36±18 yo) were reviewed. LQT was diagnosed by a positive genetic testing (n=71) or by showing abnormal T wave and long QT interval spontaneously or during epinephrin infusion in pts without discovered genetic mutation (n=34). ER was defined by > 1mm J point elevation in the inferior or lateral leads with notch or slurring pattern.ResultsQT in lead II was 433±68 msec in LQT patients and 338±41 in controls (p

Background:Patients with acute pancreatitis (AP) who require mechanical ventilation have high morbidity and mortality rates. Noninvasive positive pressure ventilation (NPPV) delivered through a mask has become increasingly popular for the treatment of acute respiratory failure (ARF) and may limit some mechanical ventilation complications. Objectives: The purpose of this retrospective, observational study was to evaluate our clinical experience with the use of NPPV in AP patients with ARF. Methods: From 1997 to 2003, we documented clinical data, gas exchange and outcome of the 62 AP patients admitted to our intensive care unit. Patients who benefited from NPPV (success) were compared with those who failed (intubated). Results:Twenty-nine patients were intubated at admission and 5 did not develop ARF. Of the 28 patients treated with NPPV, 15 were not intubated (54%). Both groups had a similar PaO2/FiO2 ratio (142 ± 21 vs. 133 ± 20; p = 0.127) and severity of illness (Ranson and Balthazar scores). Presence of atelectasis, bilateral alveolar infiltrates and abdominal distension were associated with failure of NPPV. Oxygenation improved and respiratory rate decreased significantly only in the success group. Additionally, the length of stay at the intensive care unit was significantly lower in the success group. Conclusion: NPPV is feasible and safe to treat ARF in selected patients with AP who require ventilatory support.

We report the case of a patient in whom radiofrequency catheter ablation of the AV node was initially successfully performed for persistent atrial fibrillation with fast ventricular rate, but in whom atrioventricular conduction transiently resumes following therapy with levosimendan. Plausible hypothesis are discussed as well as potential implications.

Congenital abnormalities of the coronary sinus (CS) are rare but can be responsible for unsuccessful implantation of a cardiac resynchronization therapy device. We report the case of an ectopic drainage of the CS in the left atrium. A left ventricular lead was implanted by the transseptal route.

Introduction T wave morphological changes before onset of ventricular arrhythmia are poorly known. ICD-stored intracardiac electrograms (EGM) present a unique opportunity for detecting temporal changes in repolarisation before initiation of VT/VF. Methods 57 implanted patients with St Jude Medical ICDs (45 men, 64 ± 12 yo, mean EF 34 ± 15%) were prospectively enrolled. Eleven different T wave parameters were extracted from EGM (T amplitude, T peak time, T end time, T duration between baseline crossing and between points of maximal slopes, T peak to T end, maximal ascending and descending slopes, timing of points of maximal slopes and T wave area). Values of each parameter in recordings prior to VT/VF were compared to control recordings sharing comparable QRS and T wave morphology and similar heart rate in the same pts. Results 23 VT/VF episodes (24 ± 13 beats) and 13 baseline (25 ± 9 beats) (ns) were analyzed in 12 pts (1,9 episode/pt). Mean heart rate was 71 ± 17 bpm for episodes and 66 ± 16 bpm for baseline recordings (ns). Significant differences were found in T wave amplitude, T wave maximal slopes, T peak time and timing of the T wave maximal ascending slope (although ns when corrected by the heart rate). Conclusions T wave amplitude is higher, T wave slopes are steeper and initial parts of the T wave are earlier before ventricular arrhythmia compared to baseline. Detection of T wave changes prior to VT/VF might be useful in predicting imminent arrhythmia occurrence. Download : Download full-size image Example of T wave changes before VT

Background The mechanisms of action of cardiac resynchronisation therapy (CRT) and the predictive factors to CRT's effect are not well known. The mechanical left intra-ventricular dysynchrony (LIVD) has a important physiopathological role in severe left ventricular dysfunction with wide QRS. Several studies compared LIVD before and just after CRT implant but few data are available about LIVD in the mid to long term. Methods and Results We included prospectively the 42 consecutive patients (younger than 75 yo) implanted in the University Hospital of Toulouse with ACC/AHA/ESC indications for CRT. Characteristics of the population were: male sex 88%, ischemic cardiomyopathy 45%, mean LVEF 22%, mean QRS duration 160 ms, CRT-D 98%. The echocardiographic (Pulsed Doppler and Tissue Doppler Imaging) parameters of cardiac dysynchrony were obtained at baseline and six month (or more) after CRT implant. We defined the responder group as an improvement in 1 NYHA class and no hospitalisation for heart failure (HF) during the follow up (mean duration 15 month). 62% (n = 26) were clinical responders. The echocardiographic assessment was done at 11 (6 to 20) month. There was no statistically significant difference between the “residual” mechanical dysynchrony of the responders versus the non-responders. Considering only the responders, there is no reduction of LIVD at six month after CRT. A baseline aortic pre-ejection delay > 140 ms, a non ischemic cardiomyopathy and the left ventricular activation time measured before implantation with a method described recently by Sweeney et al are the only factors of response to CRT. Conclusions The clinical response to CRT is not well correlate with the “residual” mechanical LIVD such as we measured by echocardiography (DTI and PD).

Background and purposeWe studied short term effect of CRT implantation on renal function and focused especially on the role of contrast agent dose.Method: Acute renal failure (ARF) was defined as a decrease of more than 25% of the clearance of creatinine (Cl Cr) calculated with MDRD method within four days following implantation.Results: We considered 141 patients referred for CRT implantation: male: 79%, mean age: 68 +/−12, diabetes: 71%, HTA: 38%, Cl Cr: 48 mL +/−19, median contrast dose: 48 mL (IR: 30/80), median BNP variation: −30% (IR:-58/-8), Haemoglobin (Hb) variation: −6.3% +/−11.2.ARF occurred in 19 patients (13.5%), 3 of them died and one was lost. Renal function of 14 out of the 15 remaining completely recovered.In-hospital stay longer than 10 days was more frequent in ARF group (OR = 5.18, p

IntroductionMonomorphic sustained ventricular tachycardia (MSVT) in structural heart disease (SHD) carries poor prognosis and usually needs ICD implantation. Whether successful RF ablation of VT in this setting could avoid the need of ICD implantation is largely unknown.Methods105 successive with SHD (88 men, age 64±16) were followed after RF ablation of MSVT. An ICD was not implanted either because of end stage extra cardiac pathology, advanced age or well-tolerated MSVT and preserved EF. 33% were on amiodarone and 51% on beta-blockers.Results128 procedures were performed (1,2/pt) in 4 centers. Coronary artery disease was present in 54%, right ventricular dysplasia in 10%, dilated cardiomyopathy in 10% and various SHD in 26%. Mean EF was 48±12% (14% with EF

Background The success rate of left ventricular (LV) lead implantation for cardiac resynchronization therapy (CRT) is high. Congenital abnormalities of the coronary sinus (CS) are rare but can be responsible for unsuccessful implantation. Method and result A 64-year-old male with standard indication for CRT was referred to our institution for a CRT-D implantation. Unfortunately, intubation of the CS was not possible. TEE showed a congenital CS anomaly with complete drainage of the CS into the left atrium. Because of contra-indication for general anaesthesia and thus for surgical epicardial implantation, we proposed to implant the LV lead by a transseptal approach. After the patient had given his consent, a transseptal puncture was performed via the right femoral vein. A conventional screw-in lead was implanted at the laterobasal segment of the LV using a deflectable catheter guide introduced via the left subclavian vein through the transseptal puncture. Post-implantation parameters of the LV lead were acceptable: pacing threshold 0.7 V-0.4 ms, impedance 435 ohms, R wave amplitude 5 mvolts. Right ventricular and right atrium leads were then implanted (fig 1) A post-implant CT scan confirmed the ectopic location of the CS ostium without persistent superior vena cava (fig 2). Download : Download full-size image Figure 1 Download : Download full-size image Figure 2 The patient was discharged on anticoagulation with a targeted international normalized ratio between 3 and 4. At the one- and three-month follow-up, no complication had occurred. He was in class 2 of the NYHA and had not been hospitalised. Electrical parameters remained steady. Conclusion Complete drainage of the CS in the left atrium without persistent vena cava is a rare congenital abnormality. When cardiac resynchronization therapy is needed, transseptal implantation could be a feasible alternative.

In this randomized, double-blinded study we sought to assess the analgesic efficacy of ropivacaine and bupivacaine in combination with sufentanil and the efficacy of ropivacaine alone after major abdominal surgery. Sixty patients undergoing major abdominal surgery received standardized general anesthesia combined with epidural thoracic analgesia. They were allocated to one of three groups: the BS group received postoperative patient-controlled epidural analgesia with 0.125% bupivacaine plus 0.5 microg/mL sufentanil; the RS group received 0.125% ropivacaine plus 0.5 microg/mL sufentanil; and the R group received 0.2% ropivacaine, with the patient-controlled epidural analgesia device set at bolus 2-3 mL and background infusion 3-5 mL/h. Visual analog scale scores were significantly lower during coughing in the BS group compared with the RS and R groups and in the RS group compared with the R group. The BS group required significantly less local anesthetic (milligrams per day) during the first three postoperative days compared with the RS and R groups, and the RS group, significantly less than the R group. No major side effects were noted in any group. We conclude that, after major abdominal surgery, thoracic epidural analgesia was more effective with bupivacaine than with ropivacaine when these two local anesthetics are used in a mixture with sufentanil. Ropivacaine alone was less effective than ropivacaine in combination with sufentanil.After major abdominal surgery, thoracic epidural analgesia was more effective with 0.125% bupivacaine than with 0.125% ropivacaine when these two local anesthetics were used in a mixture with 0.5 microg/mL sufentanil. Ropivacaine 0.2% alone was less effective than 0.125% ropivacaine combined with sufentanil.

Introduction T wave morphological changes before onset of ventricular arrhythmia are poorly known. ICD-stored intracardiac electrograms (IEGM) present a unique opportunity for detecting temporal changes in repolarisation before initiation of VT/VF. Methods 56 implanted patients with St Jude medical ICDs (44 men, 63 ± 12 yo, mean EF 34 ± 15%) were prospectively enrolled. Eleven different T wave parameters were extracted from IEGM (T amplitude, T peak time, T end time, T duration between baseline crossing and between points of maximal slopes, T peak to T end, maximal ascending and descending slopes, timing of points of maximal slopes and T wave area). Averaged values of each parameter in recordings prior to VT/VF were compared to control recordings sharing comparable QRS and T wave morphology and similar heart rate in the same pts. Results 22 VT/VF episodes (24 ± 13 beats) and 13 baseline (25 ± 9 beats) (ns) were analyzed in 12 pts (1,8 episode/ pt). Mean heart rate was 71 ± 17 bpm for episodes and 66 ± 16 bpm for baseline recordings (ns). Significant differences were found in T wave amplitude and slopes. Durations and timings of the different parts of the T wave did not significantly vary. Conclusions Detection of T wave changes prior to VT/VF might be useful in predicting imminent arrhythmia occurrence. T wave amplitude is higher and T wave slopes are steeper before ventricular arrhythmia compared to baseline, without significant shortening of different repolarisation times. Download : Download full-size image

Late potentials (LPS) have been shown to be predictive of ventricular tachycardia in coronary artery disease subjects, but the prevalence of LP in the general population is not as well-known. The study included 487 men without a history of cardiovascular disease (aged 50-59) living in Southwestern France. Standard-averaged high resolution electrocardiogram was performed using Butterworth filtering at 40-250 Hz. LPS were defined as two or more of the following criteria: QRS114 ms, duration of the low amplitude signals in the terminal portion of QRS38 ms, root mean square (RMS) voltage of the last 40 ms20 microV. The mean QRS duration was 97 +/- 12 ms (mean +/- SD), duration of the low amplitude signals in the terminal portion of QRS was 32 +/- 10 ms, and RMS voltage in the last 40 ms was 39 +/- 27 microV. Eight percent of subjects (95% confidence interval [CI]: 6%-11%) had a QRS duration114 ms; 22% (95% CI: 18%-26%) had a duration of low amplitude signals38 ms, and 25% (95% CI: 22%-29%) had RMS voltage in the last 40 ms20 microV. Finally, the prevalence of LP was 21% (95% CI: 18%-25%). In conclusion, according to commonly used criteria, the prevalence of LP in this healthy population of middle-aged men is 21%, close to the values found in the literature for myocardial infarction patients. Those findings indicate the need for reconsidering the definition of LPS.

Introduction: Early Repolarization (ER) in Brugada or short QT syndrome is common and has been associated to a less favourable outcome. Even if apparently paradoxical, ER can also be seen in Long QT (LQT) but prevalence and correlations to other variables are unknown. Methods: 12 leads ECG of 41 LQT patients (21 men, 37±22 yo) were reviewed and compared to 97 matched controls (54 men, 39±24 yo) LQT patients were selected by a positive genetic testing (n=33) or by showing abnormal T wave and long QT interval spontaneously or during epinephrin infusion in patients without discovered genetic mutation (n=8). ER was defined by ≥ 1 mm J point elevation in the inferior or lateral leads with a notch or slurring pattern. Presence of ER was correlated to the clinical and ECG characteristics and to the results of genetic analysis. Results: QT was 406±52 msec in LQT patients and 354±42 in controls (p≤0.0001) (QTc 433±34 versus 386±26 msec, p≤0.0001). Two LQT patients presented with ressuscitated sudden death and 4 with syncope at the time of diagnosis. 14/41 LQT patients (34%) had ER compared to 14/97 (14%) controls (p=0.008). Heart rate was not different between patients and controls (64±10bpm versus 73±20bpm, p=0.14). ER was more frequent in men (12/21, 57%) compared to women (2/20, 10%) (p=0.004) but was not correlated to age (41±22 yo with ER versus 35±22bpm, p=0.4). ER was not correlated to symptoms or cardiac events (no ER in the 2 patients with SD and in 2/4 patients with syncope versus 12/35 in asymptomatic LQT patients, p=ns). There was a trend toward longer QT in patients with ER (427±40 versus 396±54 msec in V2, p=0.09) but there was no correlations between ER and corrected QT intervals. This can be explained by the lower heart rate in patients with ER (63±10 versus 75±18bpm, p=0.03). ER was not more often seen in patients with or without mutations (11/33 versus 3/8, p=0.8), but there was more frequent ER in case of HeRG mutations (9/17) than in case of KCNQ1 or KCNJ2 mutations (2/13 and 0/3) (p=0.04) Conclusion: ER is very common in LQT patients and is related to a male gender, to a longer QT duration and to a slower heart rate but not to age or to the corrected QT duration. ER does not seem to be correlated to cardiac events in this series but may be linked to HeRG mutations. Further studies are needed for demonstrating additional mutations/variants or the existence of an early transient voltage gradient due to altered kinetics in muted potassium channels with loss of function especially for HeRG mutations.

Cardiac pacing is the treatment of choice in patients with carotid sinus syndrome (CSS). Three different pacing modes were tested in 20 patients (16 males, 4 females; mean age 75 +/- 9 years) with documented symptomatic CSS. Three carotid sinus massages (CSM) were performed in each supine patient successively paced in random order in: DDI--the reference pacing mode; DDD--automatic mode conversion (DDD/AMC) allowing automatic switching from AAI to DDD when AV block occurs; DDD/AMC plus atrial acceleration (DDD/AMC+acc); and OOO (CSM without pacing) to determine whether the vasodepressive effect was still present 10 minutes after the preceding CSM. Intraarterial blood pressure was continuously monitored. Results were expressed as the value of the mean systolic BP at T0 + 3 s + 6 s ... T0 + 30 s divided by the value of the mean systolic blood pressure prior to onset of CSM. The drop in arterial blood pressure was more severe in the DDI mode than in DDD/AMC (P < 0.001) and DDD/AMC+acc (P < 0.0001) in 20 patients. In the OOO mode, the drop in arterial blood pressure was most marked and greater than in the DDI mode (P < 0.0001). The average time between start of the CSM and onset of the drop in blood pressure was the same in the three dual chamber modes. We conclude that the DDD/AMC mode significantly improves the vasodepressor response to CSM compared to the DDI mode. There is a current trend favoring DDD/AMC+acc over DDD/AMC.

Introduction post-ischemic electrical storm (PIES) occurring shortly after the acute phase of myocardial infarction (MI) is a rare but potentially lethal phenomenon. Clinical and therapeutic options are poorly known. Methods 14 pts (12 men, 61 ± 13 years old) underwent RF ablation for intractable PIES. PIES occurred 10 ± 5 days after MI (4 months in one pt). Mean EF was 28 ± 7%. Fast monomorphic VT (10 pts), FV (8 pts) or torsades de pointes (5 pts) recurred in each pt despite maximal anti-arrhythmic therapy (mean 22 ± 13 episodes). MI was inaugural anterior MI in each but 3 pts (subendocardial in 2, inferior in 1), with one vessel disease (left descending artery) in 8 pts (2 or 3 vessels in 6). When performed (4 pts), new PTCA did not control PIES. RF ablation was performed as a last chance solution, targetting ventricular premature beats arising from the left septal Purkinje network (in all patients the arrhythmia was of Purkinje origin, defined by a sharp spike Purkinje-potential preceding ventricular activation during sinus rhythm as well as during arrhythmia). Results Abolition of Purkinje potentials and of Purkinje premature beats led to resumption of electrical storm in 12/14 pts with 1 procedure (2 in one pt). The two pts with unsuccessful RF ablation died within a few hours from intractable heart failure and recurring arrhythmias. All other pts were implanted with an ICD (two pts had already been implanted before). During a 18 ± 19 months follow-up, 3 pts present with recurring isolated VT episodes found in ICD memories. Seven pts died from cardiac or non cardiac causes (7 ± 10 months). Conclusions PIES is a rare but potentially lethal event occurring mainly in inaugural large anterior acute MI. RF ablation of initiating Purkinje-premature beats may be an efficient therapeutic solution despite the poor long-term prognosis of such patients.

Objectif Discuter l’interet du defibrillateur automatique implantable (DAI) en cas de troubles du rythme ventriculaires graves inauguraux chez l’enfant atteint de myocardiopathie spongieuse. Sujet La non compaction du ventricule gauche est une cardiopathie rare sous diagnostiquee. Elle peut etre isolee ou associee a d’autres anomalies cardiaques. La presentation clinique est extremement variable. Ses complications sont la dysfonction ventriculaire gauche, les troubles du rythme cardiaque, les accidents thrombo-emboliques systemiques et la mort subite. La frequence des arythmies est de 20 % chez l’enfant. Nous rapportons ici le cas d’un enfant de 33 mois, originaire du benin, ne de parents consanguins, chez qui le diagnostic de non compaction du ventricule gauche isolee a ete porte au decours de 3 arrets circulatoires sur fibrillation ventriculaire. Un DAI a ete pose en association avec un traitement par cordarone et aspirine. Ce cas s’integre dans une forme familiale (3 enfants atteints sur 5). Conclusion La pose d’un DAI n’est pas frequente chez le jeune enfant. Les troubles du rythme ventriculaires, dans le cadre du myocarde non compacte, peuvent cependant apparaitre comme une indication formelle y compris chez le jeune enfant.

IntroductionDC shock is commonly used for external cardioversion of cardiac arrhythmias. Incidence, characteristics and predictive factors of transient ST-segment changes after DC shock are poorly known.Methods91 consecutive pts referred for external cardioversion of atrial fibrillation (AFib) (61 men, 69±10 yo) were prospectively included. Duration and amplitude of ST elevation or depression were quantified on12 lead-ECG immediately after the first DC shock. Correlations with DC shock characteristics clinical variables, underlying heart disease, echocardiographic parameters, biological parameters, medications, anesthesic drugs as well with morphological features were made.Results18 and 20 pts underwent 200 J or 300 J monophasic and 53 pts 200 J biphasic DC shocks. Immediate success rate was 95%.We found an incidence of 48% for ST segment changes: 35% for ST elevation (0,81±0,44 mV) and 13% for ST depression (0,2±0,07 mV, p