Search

International audience; OBJECTIVE: We sought to evaluate prognostic markers of clinical outcome in asymptomatic patients with moderate to severe aortic stenosis (AS). DESIGN: Prospective follow-up of asymptomatic patients with moderate to severe AS. The patients underwent clinical and Doppler echocardiographic evaluation. SETTING: Department of Cardiology. PATIENTS: 163 patients with moderate to severe AS (aortic valve area < or =0.6 cm(2)/m(2)). MAIN OUTCOME MEASURES: Risk stratification. Predefined endpoints for assessing the outcome were the occurrence during follow-up of symptoms, aortic valve replacement or death. RESULTS: During follow-up (mean, 20 (19) months), 11 patients developed symptoms but were not operated on, 57 required aortic valve replacement and six patients died. In multivariable Cox regression analysis, four parameters that were associated with the outcome were identified: peak aortic jet velocity, left ventricular systolic (LV) longitudinal deformation, valvulo-arterial impedance and indexed left atrial area. Using receiver-operator characteristic curve analysis, a peak aortic jet velocity > or =4.4 m/s, a LV longitudinal myocardial deformation < or =15.9%, a valvular-arterial impedance > or =4.9 mm Hg/ml per m(2) and an indexed left atrial area > or =12.2 cm(2)/m(2) were identified as the best cut-off values to be associated with events. CONCLUSIONS: In asymptomatic patients with moderate to severe AS, measurements that integrate the ventricular, vascular and valvular components of the disease improve risk stratification.

The purpose of this Consensus Statement is to focus on implantable cardioverter-defibrillator (ICD) deactivation in patients with irreversible or terminal illness. This statement summarizes the opinions of the Task Force members, convened by the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS), based on ethical and legal principles, as well as their own clinical, scientific, and technical experience. It is directed to all healthcare professionals who treat patients with implanted ICDs, nearing end of life, in order to improve the patient dying process. This statement is not intended to recommend or promote device deactivation. Rather, the ultimate judgement regarding this procedure must be made by the patient (or in special conditions by his/her legal representative) after careful communication about the deactivation's consequences, respecting his/her autonomy and clarifying that he/she has a legal and ethical right to refuse it. Obviously, the physician asked to deactivate the ICD and the industry representative asked to assist can conscientiously object to and refuse to perform device deactivation.

To investigate the temporal patterns, predictors, and prognostic impact of spontaneous sinus rhythm resumption (SRR) of heart failure (HF) patients with permanent atrial fibrillation (AF) treated with cardiac resynchronization therapy (CRT).This multicentre, retrospective, longitudinal study analysed 330 consecutive HF patients with permanent AF treated with a CRT device (mean age 70 +/- 9 years, male 83%, ischaemic aetiology 44%, NYHA class III-IV 93%, mean QRS duration 167 +/- 40 ms, and mean ejection fraction 26 +/- 7%). Clinical, echocardiographic, and outcome data were collected during follow-up. Thirty-four patients experienced SRR after CRT (10.3%) at a median 4-month follow-up. The strongest independent predictors were end-diastolic diameter (EDD) [hazard ratios (HR) 4.03, 95% confidence intervals (95% CI) 1.43-11.36, P = 0.008], post-CRT QRSor=150 ms (HR 2.63, 95% CI 1.02-6.67, P = 0.05), left atrium (LA) diameteror=50 mm (HR 4.76, 95% CI 1.72-11.82, P = 0.002), and atrioventricular junction (AVJ) ablation (HR 4.27, 95% CI 1.54-11.84, P = 0.02). The coexistence of three predictors vs. zero to two predictors increased by 3.5-fold the likelihood of SRR; while the presence of all four factors improves the probability by a factor of 5.7-fold. Sinus rhythm resumption was associated with a significantly better long-term survival (log rank P = 0.03).One in every 10 HF patients with permanent AF may experience SRR after CRT. Baseline EDDor=65 mm, CRT-paced QRSor=150 ms, LAor=50 mm, and AVJ ablation appear to be predictive of this phenomenon.

International audience; A 62-year-old man with a history of smoking, hypertension, and hypercholesterolemia was admitted for an inferior ST-segment elevation myocardial infarction (Figure 1). Coronary angiography performed 1 hour after the onset of chest pain revealed that the posterolateral artery was aneurysmal and obstructed...

Objective Evaluation of safety and efficiency of trans-venous lead extraction for cardiac device-related infective endocarditis (CDIE). Methods Retrospective mono-centric study of 49 patients who underwent trans-venous lead extraction during years 2000-2008 for CDIE diagnosed on blood culture (80%) and/or lead tips culture (65%), associated with evidence of vegetation before removal on device lead or on tricuspid valve leaflet. Every patient was investigated with trans-oesophageal echocardiography. Extraction technique consisted on manual traction, use of locking device, with a femoral vein approach in 33% of cases. Results Primary trans-venous lead removal was complete in 38 patients (78%). No patients with lead implanted during the past 6 years had incomplete extraction (p=0.004). For 10 patients (20%), lead fragments persisted in implantation site (50%), or in the costo-clavicular inter space (25%). Only 5 patients (10%) requested a second procedure either per-cutaneously (3 cases), with a new failure for 1 of them, or surgically (2 cases). Twelve patients (24%) presented at least one complication: • local complications (43%) including 4 haematoma requiring 2 surgical treatment, 1 haemorrhage requiring blood transfusion and 1 arm paralysis • heart rhythm complications (21%) : atrial fibrillation, torsades de pointes, and ventricular pause (one case each) • systemic complications (36%) : • cases of severe tricuspid regurgitation, • combined septic and cardiogenic shock, • symptomatic pulmonary embolism, • sepsis. No death occured within one week of extraction. Mean vegetation size was 15-mm (±8). Largest vegetations (≥14mm) were not associated with increased risk of complications (p=0,11). Vegetation size was neither correlated with 30-days mortality (OR, 1.04; 95% CI, 0.88-1.23; p=0.64) nor with 6-months mortality (OR, 1.03; 95% CI, 0.9661.11; p=0.42). Conclusions Primary trans-venous lead removal is an efficient technique, particularly in case of recent lead implantation, at least in an experienced center. Rate of systemic complications were 10%.No correlation between vegetation size and morbidity was observed.

BackgroundRight ventricular (RV) function has been proven to be a major determinant of clinical outcome in Chronic Heart Failure (CHF). The right and left (L) ventricles inter dependence has been weakly evaluated but might impact on response to treatments and prognosis.AimWe sought to assess the impact of RV-function on LV-function by studying longitudinal and radial strains in CHF-patients selected for cardiac resynchronization therapy (CRT).MethodsThirty-eight consecutive CHF-patients (New York Heart Association class III/IV, left ventricular ejection fraction [LVEF] less than 35%, QRS greater than 120 ms) were studied before and after 6-month of CRT. RV function was assessed by tricuspid annulus plane systolic velocity (Vs) with a cut-off of 11.5 cm/s. Global LV longitudinal strain (GLS) was measured (from the apical 4-chamber, apical 3-chamber and apical 2-chamber views) before and after CRT. Mean radial strain was measured from the parasternal mid-ventricular view. Reverse remodeling was defined by echocardiography at 6-month by a decrease in LV end-systolic volume ≥ 15%.ResultsEighteen patients had RV-dysfunction (mean Vs=7.6 ±1.2cm/s) and 20 had normal RV-function (13.6±2.7cm/s). LVEF and volumes were non different between groups. Patients with RV-dysfunction had significantly worst global longitudinal strain before CRT (A-4Ch=-5.3±1.5% vs. -7.4±2.2%, p=0.01; A-2Ch=-5.7±1.2% vs. -9±2%, p

International audience; AIMS: Little is known about the incidence of paroxysmal atrial tachycardias (PAT) in patients with heart failure (HF). The availability of cardiac resynchronization therapy (CRT) devices with extended diagnostics for AT enables continuous monitoring of PAT episodes. The aim of the study was to assess the incidence over time of PAT in HF patients treated with CRT. METHODS AND RESULTS: Consecutive patients in NYHA functional class III or IV despite optimal drug therapy, QRS duration > or = 130 ms, left ventricular ejection fraction < or = 35%, and left ventricular end-diastolic dimension > or = 55 mm were eligible for enrolment. Patients with permanent or persistent atrial fibrillation (AF) were not included in the study. The first follow-up examination was performed 2 weeks after implantation, to optimize atrial sensing and CRT. Subsequent follow-up examinations were carried out 15 and 28 weeks after implantation, to collect the telemetric data. A total of 173 patients (67 +/- 11 years, M 116) were enrolled. Complete arrhythmia monitoring data were available from 120 patients over a mean follow-up of 183 +/- 23 days. Atrial tachycardia episodes were detected through telemetry in 25 of 120 patients (21%) during at least one follow-up examination. Atrial tachycardia episodes were recorded in 29 and 17% (P = NS) of patients with and without previous history of AF, respectively. CONCLUSION: More than 20% of the overall HF patient population treated with CRT suffer PAT episodes. Paroxysmal atrial tachycardia may interfere with response to CRT. Therefore, telemetric data may be relevant to drive the appropriate therapy in each patient.

Tolosana et al. have reported the results of a randomized study, which compared two procedures in preparation for implantation of pacemakers or cardioverter defibrillators (ICDs) in a small population of chronically anticoagulated patients at high risk of thrombo-embolic events.1 One group was randomly assigned to continued oral anticoagulation (OAC) reduced to a target international normalized ratio (INR) near 2.0 for the procedure, and the other to temporary replacement of OAC by heparin, as recommended by current guidelines for high-risk patients.2–4 Considering the high proportion of chronically anticoagulated patients among the large population of cardiac device recipients, this is an important issue. In the recently published French PEOPLE registry,5 11% of patients remained on OAC and nearly 20% received heparin at the time of procedure. This patient population is exposed to a dual risk during the critical period of re-arrangement of anticoagulation: (i) haemorrhage, particularly procedure-related pocket haematoma; and (ii) thrombo-embolism from under-anticoagulation during the peri-operative period. Furthermore, the choice of anticoagulation strategy directly influences the duration of hospitalization and overall cost of treatment. Except in special cases, OAC should not be withheld for minor procedures associated with a low risk of haemorrhage. In the presence of mechanical valve prostheses, it is currently recommended to continue OAC with an INR near 2.0.3 The implantation of cardiac devices is associated with an intermediate risk of local haemorrhage, which complicates procedures performed during full anticoagulation. The risk of pocket haematoma after pacemaker or ICD implantation under anticoagulation varies between 20 and 25% among past and recent studies including small numbers of patients,7 though it was lower in recently published, large, prospective single- or multicentre registries.4,8 Wiegand et al. found a 4.9% overall risk of pocket haematoma after 3164 pacemaker or ICD implantations, which … *Corresponding author: Tel: +33 299 282 525, Fax: +33 299 282 510, Email: jean-claude.daubert{at}chu-rennes.fr

International audience; Cardiac resynchronization therapy (CRT) has been shown to induce a spectacular effect on left ventricular (LV) function in certain patients. Our aim was to analyze and characterize the super-responders (SRs) to CRT using echocardiography in 186 patients with a conventional indication according to the European Society Cardiology guidelines. The investigation took place before and 6 months after implantation. CRT-SRs were defined by an improvement of the New York Heart Association functional class and LV ejection fraction to > or = 50% in absolute values associated with a relative LV end-systolic volume reduction of > or = 15%. Of the 186 patients, 18 (9.7%) were identified as CRT-SRs and had a significantly lower prevalence of ischemic etiology (11%), lower LV dimensions, lower left atrial volume, and greater global longitudinal strain at baseline. Receiver operating characteristics curves identified global longitudinal strain as the strongest parameter for predicting CRT-SRs, with a cutoff value of -12% (area under the curve 0.87, sensitivity 71%, and specificity 85%, p

International audience; INTRODUCTION: Congenital long-QT syndrome (LQTS) is a sporadic or familial inherited arrhythmia. It can lead to sudden death by ventricular fibrillation which occurs at any age but particularly during infancy. Recent studies of postmortem molecular analysis in infants who died of unexplained sudden infant death syndrome (SIDS) showed abnormal mutations to LQTS in 10% to 12%. Current methods of etiologic investigation of sudden infant death syndrome do not allow the diagnosis of LQTS. A targeted anamnesis together with systematic electrocardiograms of first- and second-degree relatives could be an efficient LQTS diagnostic tool. Therefore, we propose to include them in screening procedures for SIDS etiologies. CONCLUSION: LQTS accounts for a significant number of unexplained SIDS. We suggest adding a systematic familial electrocardiographic screening to the current etiologic investigations in order to track congenital LQTS in relatives.

International audience; AIMS: Heart failure with preserved ejection fraction (HFPEF) is common but not well understood. Electrical dyssynchrony in systolic heart failure is harmful. Little is known about the prevalence and the prognostic impact of dyssynchrony in HFPEF. METHODS AND RESULTS: We have designed a prospective, multicenter, international, observational study to characterize HFPEF and to determine whether electrical or mechanical dyssynchrony affects prognosis. Patients presenting with acute heart failure (HF) will be screened so as to identify 400 patients with HFPEF. Inclusion criteria will be: acute presentation with Framingham criteria for HF, left ventricular ejection fraction>or=45%, brain natriuretic peptide (BNP)>100 pg/mL or NT-proBNP>300 pg/mL. Once stabilized, 4-8 weeks after the index presentation, patients will return and undergo questionnaires, serology, ECG, and Doppler echocardiography. Thereafter, patients will be followed for mortality and HF hospitalization every 6 months for at least 18 months. Sub-studies will focus on echocardiographic changes from the acute presentation to the stable condition and on exercise echocardiography, cardiopulmonary exercise testing, and serological markers. CONCLUSION: KaRen aims to characterize electrical and mechanical dyssynchrony and to assess its prognostic impact in HFPEF. The results might improve our understanding of HFPEF and generate answers to the question whether dyssynchrony could be a target for therapy in HFPEF.

International audience; BACKGROUND: Cardiac resynchronization therapy (CRT), which improves left ventricular (LV) function and reverses LV remodeling, is an established therapy for advanced heart failure with prolonged QRS duration. The aim of this study was to examine whether CRT improves atrial function and induces atrial reverse remodeling. METHODS: A total of 46 patients with heart failure (mean age, 66.7 +/- 10.4 years) who underwent CRT were evaluated with echocardiography before and after 6 months of optimized CRT. Atrial function and LV function were assessed with M-mode, two-dimensional echocardiography, Doppler, tissue Doppler velocity, and strain (epsilon) imaging. LV reverse remodeling was defined as a reduction in LV end-systolic volume of >15%. RESULTS: In responders (n = 23), significant improvements in left atrial (LA) functional, structural, and anatomic remodeling were observed. Maximum LA area and volume decreased, the LA emptying fraction increased, A' increased, and LA epsilon increased from 25.6 +/- 11.0% to 42.6 +/- 10.4% (P < .05 overall). LA reverse remodeling was correlated with baseline LA volume (R = 0.45). Although the correlation was not significant (r = 0.24), LA reverse remodeling was also more frequent in patients with LV reverse remodeling. CONCLUSIONS: In patients with LV remodeling, significant LA reverse remodeling after CRT could be observed and detailed on transthoracic echocardiography.

International audience; Echocardiography is an essential facet of monitoring patients with heart failure. However, results of echocardiographic detection and quantification of mechanical dyssynchrony are not currently recommended as grounds for the deployment of biventricular (Biv) resynchronisation therapy. Ten years of research in the field of dyssynchrony within echocardiography have resulted in two negative studies which have, to some extent, discredited this technique. However, the research conducted has at least allowed us to refine our understanding of mechanical dyssynchrony and its management. New quantification techniques and generalised access to digital imagery and processing have renewed hopes that the performance of echocardiography in this field will soon improve. We therefore propose new criteria, to be evaluated as per PROSPECT standard methodology. In the review of the literature presented here, we suggest combining the echocardiography parameters for an individual and physiopathological approach, while waiting for more prospective studies to be conducted before issuing any recommendations.

International audience; Aims : Exercise stress testing (EST) is recommended by guidelines to risk-stratify patients with asymptomatic valvular aortic stenosis (AS), though the role of quantitative exercise-Doppler echocardiography has rarely been studied. This prospective study sought to correlate standard EST results with the haemodynamic measurements made during exercise by Doppler echocardiography. Methods and results : We performed rest and semi-supine exercise Doppler echocardiography in 44 consecutive patients (mean age = 68 ± 12 years) with aortic valve areas ≤0.6 cm2/m2. The effective aortic valve area (EOA), cardiac output (CO), maximal transvalvular velocity, and pulmonary pressure were monitored over the test. No serious adverse event was observed. EST was positive in 26 (Group 1) and negative in 18 (Group 2) patients. Baseline echocardiographic measurements were similar (EOA 0.77 ± 0.15 vs. 0.78 ± 0.14 cm2; CO 5.5 ± 1.6 vs. 5.9 ± 2 L/min) in both groups. Exercise-induced changes in CO (+2.9 ± 2 vs. +4.3 ± 1.8 L/min, P = 0.04) and EOA (−0.04 ± 0.18 vs. +0.15 ± 0.24 cm2, P = 0.015) were significantly greater in Group 2. A correlation between changes in EOA and changes in CO during exercise was observed, but significantly higher in Group 2 (P = 0.04). Conclusion : In the presence of severe asymptomatic AS, exercise Doppler echocardiography, assessing the mechanisms behind a positive EST, appears very promising but further studies with prognosis assessment remain necessary.

Background: Cardiac Resynchronization Therapy (CRT) induces LV reverse remodeling that translates into symptom relief and improved survival in New York Heart Association (NYHA) symptom class III/IV heart failure (HF). We hypothesized that CRT would also result in LV reverse remodeling in NYHA class I/II (asymptomatic or minimally symptomatic) HF and slow disease progression. Method: All patients in the RE synchronization re VE rses R emodeling in S ystolic left v Entricular dysfunction (REVERSE) study had an EF120ms and had optimal HF therapy for at least 1 month. Echograms were obtained at baseline, pre-hospital discharge (PHD), 6 and 12 months. At the PHD visit two limited echos were performed (one with CRT OFF and one with CRT ON), to assess the acute mechanical effect of pacing. LV volume indices, EF, LV mass and severity of mitral regurgitation (MR) were quantified at all time points by a Core Echo lab. Results: Of 610 patients, 82% had NYHA class II and 18% had class I HF. Patients were randomized 2:1 to CRT ON (n=419) or CRT OFF (n=191). LV volume indices at end-systole and end-diastole decreased and EF increased significantly from baseline to 12 months in CRT ON, but did not change in CRT OFF. LV mass and severity of MR did not change in either group at 12 months (Table ). When CRT ON was switched to CRT OFF at PHD, there were no significant acute changes in LV size or function. Conclusion: CRT results in major structural and functional LV reverse remodeling in patients with NYHA class I/II HF that may delay the natural disease progression. The progressive reverse LV remodeling is demonstrated on top of the attenuation seen with optimal medical therapy in NYHA class I/II (CRT OFF group). The echo findings in REVERSE may have important clinical implications for use of CRT in the optimal therapy of patients with NYHA class I/II heart failure. Table. Mean ± S.D. (n) Echocardiographic Parameters: CRT ON vs. CRT OFF

BACKGROUND AND AIM: In an animal model VLDL-triglyceride secretion is highly dependent on stearoyl-coA desaturase (SCD) activity and could explain abdominal fattening. The aim was to assess the relationship of plasma palmitoleic acid content, a product of SCD activity, with triglyceridemia and abdominal adiposity in humans. METHODS: We evaluated 134 healthy men. Plasma palmitoleic acid content was used as an indirect measurement of SCD activity because that enzyme catalyzes the desaturation from saturated to monounsaturated fatty acids and palmitoleic acid intake is very small. RESULTS: Subjects with triglycerides > or =75th percentile had a higher palmitoleic acid content than those with triglycerides

The Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction (REVERSE) study is a randomized controlled trial currently assessing the safety and efficacy of cardiac resynchronization therapy in patients with asymptomatic left ventricular (LV) dysfunction with previous symptoms of mild heart failure. This paper describes the baseline characteristics of randomized patients; 610 patients with New York Heart Association (NYHA) class II (82.3%) heart failure or asymptomatic (NYHA class I) LV dysfunction with previous symptoms (17.7%) were randomized in 73 centers. The mean age was 62.5+/-11.0 years, the mean LV ejection fraction was 26.7%+/-7.0%, and the mean LV end-diastolic diameter was 66.9+/-8.9 mm. A total of 97% of patients were taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and 95.1% were taking beta-blockers, which were at the target dose in 35.1% of patients. Compared with previous randomized cardiac resynchronization therapy trials, REVERSE patients are on better pharmacologic treatment, are younger, and have a narrower QRS width despite similar LV dysfunction.

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines/rules). In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed including the assessment of the risk/benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2 . View this table: Table 1 Classes of recommendations View this table: Table 2 Levels of evidence The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified …

Background: Cardiac resynchronization therapy (CRT) improves heart failure (HF) symptoms through a reduction of cardiac mechanical dyssynchrony. Mechanical dyssynchrony is currently estimated by electrical dyssynchrony (QRS duration). It is known that electrical and mechanical dyssynchrony are not well correlated in HF patients. However, there is limited information about whether this relationship might be influenced by the underlying cardiomyopathy. Methods: Doppler echocardiography was performed in 88 patients presenting with heart failure due to ischemic (n = 42) or nonischemic (n = 46) heart disease, left ventricular ejection fraction

ObjectivesWe compared the effects of triple-site versus dual-site biventricular stimulation in candidates for cardiac resynchronization therapy.BackgroundConventional biventricular stimulation with a single right ventricular (RV) and a single left ventricular (LV) lead is associated with persistence of cardiac dyssynchrony in up to 30% of patients.MethodsThis multicenter, single-blind, crossover study enrolled 40 patients (mean age 70 ± 9 years) with moderate-to-severe heart failure despite optimal drug treatment, a mean LV ejection fraction of 26 ± 11%, and permanent atrial fibrillation requiring cardiac pacing for slow ventricular rate. A cardiac resynchronization therapy device connected to 1 RV and 2 LV leads, inserted in 2 separate coronary sinus tributaries, was successfully implanted in 34 patients. After 3 months of biventricular stimulation, the patients were randomly assigned to stimulation for 3 months with either 1 RV and 2 LV leads (3-V) or to conventional stimulation with 1 RV and 1 LV lead (2-V), then crossed over for 3 months to the alternate configuration. The primary study end point was quality of ventricular resynchronization (Z ratio). Secondary end points included reverse LV remodeling, quality of life, distance covered during 6-min hall walk, and procedure-related morbidity and mortality. Data from the 6- and 9-month visits were combined to compare end points associated with 2-V versus 3-V.ResultsData eligible for protocol-defined analyses were available in 26 patients. No significant difference in Z ratio, quality of life, and 6-min hall walk was observed between 2-V and 3-V. However, a significantly higher LV ejection fraction (27 ± 11% vs. 35 ± 11%; p = 0.001) and smaller LV end-systolic volume (157 ± 69 cm3 vs. 134 ± 75 cm3; p = 0.02) and diameter (57 ± 12 mm vs. 54 ± 10 mm; p = 0.02) were observed with 3-V than with 2-V. There was a single minor procedure-related complication.ConclusionsCardiac resynchronization therapy with 1 RV and 2 LV leads was safe and associated with significantly more LV reverse remodeling than conventional biventricular stimulation.

Aims To assess procedural characteristics and adjudicated procedure-related (≤30 days) major adverse events among patients who underwent cardiac resynchronization therapy (CRT) implantation in the CARE-HF study. The CARE-HF study shows that CRT improves symptoms and reduces morbidity and mortality in New York Heart Association (NYHA) class III/IV chronic heart failure (CHF) patients. However, safe and proper implantation of pacing systems remains key to effective CRT delivery. Methods and results Generalized linear modeling was used to examine the relationships between first implant success/failure and: NYHA class; beta-adrenergic blocker use; underlying ischemic vs. non-ischemic heart disease; history of coronary artery bypass graft or valve surgery; left ventricular (LV) end-diastolic volume ≤ vs. >300 cm3; and, influence of the participating study-centres. Implantation was attempted in 404/409 patients assigned to CRT, and in 65/404 patients assigned to medical therapy. Among these 469 patients, 450 (95.9%) received a successfully implanted and activated device. Complications occurred within 24 h in 47 patients (10.0%), mainly lead dislodgments ( n = 10, 2.1%) and coronary sinus dissection/perforation ( n = 10, 2.1%), and between 24 h and 30 days in 26 patients (5.5%), mainly lead dislodgment ( n = 13, 2.8%). Mean LV lead stimulation threshold was significantly higher than at the right atrium or right ventricle, though remained stable, delivering effective, and reliable CRT. Implanting experience was the only predictor of procedural outcome. Conclusion Transvenous CRT system implantation, using a CS lead designed for long-term LV pacing, was safe and reliable. As implanting centres become more experienced, this success rate is expected to increase further.

Objective Doppler echocardiography is well recognized as the primary noninvasive imaging technique to assess global and regional cardiac function. Cardiopulmonary exercise testing has become a powerful tool to predict outcome in chronic heart failure (CHF). We looked for cardiac determinants, using resting echocardiographic parameters, of exercise tolerance in patients with CHF. Methods Transthoracic echocardiography and standardized cardiopulmonary exercise testing were performed in 75 patients (59 ± 11 years) with CHF, New York Heart Association functional class II to III. Systolic and diastolic function, filling pressures, and left ventricular, right ventricular, and left atrial (LA) regional function were assessed using Doppler tissue velocities and strain values. Results Maximal workload (86 ± 41 W) and peak oxygen (14.6 ± 3.1 mL/min/kg) correlated with left ventricular filling pressure estimates (E/Ea and E/Vp) but also with end-diastolic pulsed Doppler tissue velocity at the mitral annulus (Aa), LA volume, and regional LA function assessed by strain analysis. In multivariate analysis, maximum workload and peak oxygen were shown to correlate with right ventricular peak strain, although Aa and E/Ea were the best predictors of exercise capacity. Conclusion Capacity to exercise in patients with CHF is understandable by resting echocardiography. Filling pressures, and LA and right ventricular functions, are its cardiac best determinants. Adding Aa peak velocity in resting echocardiographic evaluation of patients with CHF is found useful.

Background: Biventricular (BiV) stimulation lowers morbidity and mortality in patients with drug-refractory congestive heart failure (CHF), depressed left ventricular (LV) function, and ventricular dyssynchrony in absence of indication for permanent cardiac pacing. This pilot, single-blind, randomized, cross-over study examined the safety and efficacy of upgrading conventional pacing systems to BiV stimulation in patients with advanced CHF. Methods: We included 56 patients in New York Heart Association (NYHA) functional classes III or IV despite optimal drug treatment and ventricular dyssynchrony (interventriclar delay >40 ms or LV preejection delay >140 ms) in need of pacemaker replacement. We compared the patients' functional status, arrhythmias, and standard echocardiographic measurements during 3 months of conventional, single right ventricular (RV) versus 3 months of BiV stimulation. Results: There were 44 patients in the cross-over phase. QRS duration was shortened by 23% and LV preejection delay by 16% with BiV stimulation. NYHA functional class, 6-minute hall walk and quality of life score were significantly improved with BiV stimulation compared with single RV pacing by 18%, 29%, and 19%, respectively. No significant difference was observed in the ventricular arrhythmia burden or LV reverse remodeling between the 2 periods. Conclusions: This pilot study showed that upgrading from RV pacing to BiV pacing significantly improves symptoms and exercise tolerance in chronically paced patients with advanced CHF and mechanical dyssynchrony.

AIMS: The benefits of cardiac resynchronization therapy (CRT) on functional status, left ventricular (LV) remodelling and survival in patients with drug-refractory congestive heart failure (CHF), LV systolic dysfunction, and wide QRS have been demonstrated in randomized trials. However, the impact of CRT on right ventricular (RV) function, an independent prognostic factor in CHF remains questionable. This study examined the acute effects of various pacing modes on RV function in recipients of CRT systems. METHODS AND RESULTS: Echocardiographic examinations were performed in 15 patients (median age: 67 years, range 49-78), to compare RV function during atrial (AAI), RV and LV pacing, and biventricular (BiV) pacing, in random order. At baseline, the median LV ejection fraction was 20% (range 10-35) and the median LV end-diastolic diameter was 78 mm (range 62-85). Right ventricular function was impaired, with a median 36% fractional shortening of RV surfaces (7-59). Tissue Doppler systolic peak of velocity (Sa) recorded at the tricuspid annulus increased significantly from 9.9 cm/s (range 4.7-16.5) during AAI pacing, 10 cm/s (range 5.4-20.3) during RV pacing, and 11.7 cm/s (range 4.6-16.7) during LV pacing to 12.6 cm/s (range 6.6-19.1) during BiV pacing (P < 0.01). Trends toward improvements in other indices of RV function, particularly myocardial performance index and systolic excursion of the tricuspid annulus, were also observed. CONCLUSIONS: This short-term study showed a significant improvement in RV systolic function during BiV pacing compared with AAI, RV, or LV pacing in CRT recipients.

Background The rate of pacemaker (PM) implantations is continuously growing. A large number of elderly patients is expected to be implanted in the future. We aimed at analyzing the short and long-term outcome after PM replacement in nonagenarians. Methods Patients aged ≥90 yo referred for PM replacement from January 2004 to July 2014 were retrospectively included. The primary clinical endpoint was total mortality. Results 62 patients were included (93.3±2.9yo at the time of PM replacement). During the follow-up, 37 patients (59.7%) died. Survival rates were 84.2% (95%CI:71.8-91.5%), 66.9% (95%CI:51.8-78.2%) and 22.7% (95%CI:10.6-37.7%) after 1, 2 and 5 years, respectively. Atrial fibrillation (OR 2.44, 95%CI:1.07-5.58) and non-physiological pacing, (OR 2.52, 95%CI:1.12-5.65) were independent predictors of mortality. Conclusion PM replacement in nonagenarians is a safe and straightforward procedure. Patients living for a median time of 30 months after the replacement. Download : Download full-size image Figure: Survival for nonagenarians after PM replacement

Dietary habits play a major role in cardiovascular disease risk but few simple nutrition assessment tools are available for clinical practice. We developed a 14-item food frequency questionnaire to evaluate dietary patterns in relation with coronary risk in a French population.This food frequency questionnaire gave different scores of intake: saturated fatty acids (six questions), mono-unsaturated fatty acids, Omega-3 and Omega-6/Omega-3 polyunsaturated fatty acids (five questions), and fruits and vegetables (three questions). Validity was assessed against a 7-day dietary history (n = 49 subjects) and against biomarkers (n = 181). The food frequency questionnaire was also administered twice with an interval of 15 days to evaluate its reproducibility (n = 20).Validity against dietary history was assessed with Spearman correlation coefficients which ranged from 0.47 (fruits and vegetables) to 0.63 (polyunsaturated fatty acids/saturated fatty acids) (all P0.05), with a mean value of 0.54. On average, 39% of the subjects were classified in the same quartile with the food frequency questionnaire and the dietary history and 84% in the same or adjacent quartile. Biomarker-based validity using Spearman correlation coefficients varied from 0.21 (saturated fatty acids) to 0.53 (Omega-3 polyunsaturated fatty acids) (all P0.05), with a mean value of 0.35. On average, 37% of the participants were classified in the same quartile with the food frequency questionnaire and the corresponding biomarkers and 73% in the same or adjacent quartile. Reproducibility assessed by the intraclass correlation coefficient ranged from 0.71 (mono-unsaturated fatty acids) to 0.93 (global score), with a mean value of 0.81.We validated a short food frequency questionnaire for dietary pattern assessment in coronary prevention.

Whilst the CArdiac REsynchronization in Heart Failure (CARE-HF) trial has shown that cardiac resynchronization therapy (CRT) leads to reduced morbidity and mortality, the cost-effectiveness of this therapy remains uncertain. The aim of this study was to evaluate the incremental cost per quality adjusted life year (QALY) gained and incremental cost per life year gained of CRT plus medical therapy compared to medical therapy alone.This prospective analysis based on intention to treat data from all patients enrolled in the CARE-HF trial at 82 clinical centres in 12 European countries. A total of 813 patients with New York Heart Association class III or IV heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony were randomized to CRT plus medical therapy (n = 409) vs. medical therapy alone (n = 404). During a mean follow-up of 29.4 months CRT was associated with increased costs (4316, 95% CI: 1327-7485), survival (0.10 years, 95% CI: -0.01-0.21), and QALYs (0.22, 95% CI: 0.13-0.32). The incremental cost-effectiveness ratio was 19 319 per QALY gained (95% CI: 5482-45 402) and 43 596 per life-year gained (95% CI: -146 236-223 849). These results were sensitive to the costs of the device, procedure, and hospitalization.Treatment with CRT appears cost-effective at the notional willingness to pay threshold of 29 400 (20,000 pounds sterlings) per QALY gained.

Background: \ud Cardiac resynchronization reduces symptoms and improves left ventricular function in\ud many patients with heart failure due to left ventricular systolic dysfunction and cardiac\ud dyssynchrony. We evaluated its effects on morbidity and mortality.\ud Methods: \ud Patients with New York Heart Association class III or IV heart failure due to left ventricular\ud systolic dysfunction and cardiac dyssynchrony who were receiving standard pharmacologic\ud therapy were randomly assigned to receive medical therapy alone or with cardiac\ud resynchronization. The primary end point was the time to death from any cause or an\ud unplanned hospitalization for a major cardiovascular event. The principal secondary end\ud point was death from any cause.\ud Results: \ud A total of 813 patients were enrolled and followed for a mean of 29.4 months. The primary\ud end point was reached by 159 patients in the cardiac-resynchronization group, as\ud compared with 224 patients in the medical-therapy group (39 percent vs. 55 percent;\ud hazard ratio, 0.63; 95 percent confidence interval, 0.51 to 0.77; P

To assess the intensity and daily reliability of the six-minute walk test (6MWT) in patients with moderate chronic heart failure (CHF).Evaluation of testing protocol.Hospitalized care.CHF patients under optimal drug treatment (CHF-D, n=12) or optimal drug treatment plus multisite cardiac pacing (CHF-P, n=12).Not applicable.Peak values of oxygen uptake (VO2) and heart rate during a symptom-limited, treadmill exercise test and VO2, heart rate, and distance during 2 6MWT sessions (morning and afternoon). The 6MWT intensity was estimated by the ratio (%) of VO2 and heart rate values measured at the end of this test in relation to the respective peak values obtained during the treadmill exercise test.Subjects' VO2 and heart rate during the 6MWT were lower (P.001) and were about 90% of the peak values (VO2: CHF-D, 90.5%+/-11.1%; CHF-P, 93.0%+/-13.2%; heart rate: CHF-D, 90.6%+/-6.6%; CHF-P, 91.4%+/-9.6%). The distance walked during both 6MWT sessions did not differ significantly, with low coefficients of variation (or =2.0%) and high intraclass correlation coefficients (or =.98). In CHF-D only, the patients' VO2 and heart rate were significantly (P.01, P.05, respectively) higher during the afternoon session.Despite an intensity significantly lower but close to that of the symptom-limited exercise test, the 6MWT was well tolerated in both CHF groups. In these populations, the 6MWT is reliable on a daily basis, for the distance walked. However, for assessing VO2 and heart rate values in CHF-D patients, the 6MWT must always be performed at the same time of day.

Atrial conduction disorders are frequent in elderly subjects and/or those with structural heart diseases, mainly mitral valve disease, hyperthrophic cardiomyopathies, and hypertension. The resultant electrophysiological and electromechanical abnormalities are associated with a higher risk of paroxysmal or persistent atrial tachyarrhythmias, either atrial fibrillation, typical or atypical flutter or other forms of atrial tachycardias. Such an association is not fortuitous because intra- and interatrial conduction abnormalities delays disrupt (spatial and temporal dispersion) electrical activation, thus promoting the initiation and perpetuation of reentrant circuits. Preventive therapeutic interventions induce variable, sometimes paradoxical effects as with the proarrhythmic effect of class I antiarrhythmic drugs. Similarly, atrial pacing may promote proarrhythmias or an antiarrhythmic effect according to the pacing site(s) and mode. Multisite atrial pacing was conceived to correct, as much as possible, abnormal activation induced by spontaneous intra- or interatrial conduction disorders or by single site atrial pacing, which are situations responsible for commonly refractory arrhythmias. Atrial electrical resynchronization can also be used to correct mechanical abnormalities like left heart AV dyssynchrony resulting from intraatrial conduction delays.

BackgroundCardiac resynchronization Therapy (CRT) improves left ventricular ejection fraction (LVEF) in patients with congestive heart failure, LV systolic dysfunction and a wide QRS complex. Previous reports suggest that CRT may also induce electrical remodeling but the impact on clinical outcome remains unknown.ObjectiveWe sought to determine 1) if chronic CRT induces a relevant shortening of the intrinsic QRS (iQRS), 2) whether changes in the native conduction system correlate with clinical or echocardiographic response to CRT and 3) to identify predictors of iQRS width shortening.MethodsWe prospectively included 85 consecutive patients with left bundle branch block who received a CRT device in 3 French centers. NYHA class, iQRS duration, LVEF and left ventricular volumes were assessed before and one year after CRT implantation. Clinical and echocardiographic were defined respectively as NYHA class improvement >1 class without heart failure hospitalization and an increase of LVEF by ≥10% and/or a decrease in LVESV by ≥15%. Electrocardiographic responders were defined as a decrease in iQRS duration by ≥20msec.ResultsBaseline and 1-year follow-up mean iQRS durations were respectively 168.0±19.7ms and 149.6±31.6ms (p

Background The prevalence of atrial arrhythmias (AAr) in patients with heart failure (HF) is high, namely in HF with preserved ejection fraction (HFpEF). KaRen study is a French and Swedish prospective registry enrolling patients with an acute HFpEF and reassessing these patients 4–8 weeks later after conventional HF treatment. Aim We sought to define the exact prevalence and the main clinical correlates of AAr diagnosed in the patients included in KaRen. Method 535 patients were prospectively recruited and 58.5% had a history of AAr. Clinical characteristics, co-morbidities, risk factors, left ventricular ejection fraction, blood chemistry and drug treatment were recorded at baseline and 4–8 weeks later. Results The main characteristics at baseline and 4–8 weeks follow-up of the 313 pts with a history of AAr (AAr+) and of the 220 without AAr (AAr-) are displayed in the table. Patients with AAr were older (p=0.0004) and tend to have higher NT-proBNP levels at baseline. There were no significant differences for diabetes, Serum creatinin, hemoglobin or left ventricular ejection fraction. In the 313 patients AAr+, 69% were treated by beta-blockers at the admission (significantly more than in group AAr-, p=0.0034), 59.7% were treated with an ACE-inhibitor, 60% got an oral anticoagulant (p Conclusion AAr are extremely prevalent in patient admitted for HFpEF. Prevalence increases with increasing age and higher blood pressure. It leads to significantly more prescription of beta-blockers. Interestinglly, NT-proBNP decreased more in AAr+ patients after treatment. Table – Main characteristics. Mediane [25 – 75 th pctl] AAr+ N= 313 (58.5%) AAr- N=220 (41.5%) p-value Age 80[73–84] 77[70–84] 0.003 Body Mass Index 28[24–32] 25[25–33] ns Left ventricular ejection fraction 55 [50–60] 55[50–60] ns Systolic blood pressure (mm Hg) 144[125–160] 151[132–180] 0.0002 NT-proBNP admission 2654 [1356–4921] 2113 [1040–4630] 0.06 NT-proBNP 4–8 weeks 1710 [819-2800] 2113 [1040-1948]

Mutations in the SCN5A gene can lead to the Brugada syndrome, a genetically inherited form of idiopathic ventricular fibrillation that has a characteristic ECG phenotype usually restricted to precordial leads V1-V3. We identified a novel G752R SCN5A missense mutation leading to various degrees of the Brugada ECG phenotype in members of a French family. In the proband, the G752R mutation produced ST segment elevation and prominent J wave in leads II, III, and aVF. In four other relatives, ST segment elevation in the right precordial but not in the inferior leads was observed either spontaneously or under flecainide challenge. Recombinant G752R mutant exhibited a markedly reduced Na+ current amplitude and a voltage shift in both activation and inactivation curves. The mutant was found in all affected but not in nonaffected family members. One additional gene-carrier had an almost normal ECG (silent gene-carrier). We provide genetic demonstration that Brugada ECG anomalies related to a unique SCN5A mutation can be observed either in the inferior or the right precordial leads.

ObjectivesWe sought to assess the efficacy of biventricular pacing with respect to both peak and submaximal measures of exercise in patients with New York Heart Association class III heart failure (HF) and intraventricular conduction delay in a randomized, blinded study.BackgroundSubmaximal and maximal changes in exercise capacity need evaluating in this patient population with this novel therapy.MethodsGraded exercise and 6-min walk tests were performed in patients randomized to three months each of active (atrio-biventricular) and inactive pacing. Minute ventilation (VE), oxygen uptake (VO2), ventilated carbon dioxide (VCO2) and heart rate were measured in patients achieving a respiratory quotient >1 (n = 30). Oxygen pulse, anaerobic threshold (AT) and ventilatory efficiency (VE/VCO2) were calculated.ResultsActive biventricular pacing increased peak VO2(15.8 ± 4.3 vs. 14.4 ± 4.6 ml/kg/min, p = 0.02), exercise time (501 ± 223 s vs. 437 ± 233 s, p < 0.001) and oxygen pulse (9.3 ± 2.8 vs. 8.1 ± 3.1 ml/beat, p < 0.01) compared with inactive pacing. The submaximal measures of exercise capacity significantly increased with active pacing: AT (11.2 ± 4.1 ml/kg/min vs. 9.5 ± 2.3 ml/kg/min, p = 0.02) and 6-min walk (414 ± 94 m vs. 359 ± 94 m, p = 0.001). Minute ventilation/ventilated carbon dioxide improved (32 ± 9 vs. 36 ± 11, p = 0.03) with normalization of the VE/VCO2slope in 59% of patients (chi-square test, p = 0.002) with active pacing.ConclusionsBiventricular pacing may improve maximal and submaximal exercise capacity in patients with advanced HF and intraventricular conduction delay.

Despite continuous progress in drug therapy, many patients are still progressing into advanced heart failure, a very poor condition in terms of quality of life and prognosis. Therapeutic resources are quite limited at that end-stage. Heart transplantation may only be proposed to a small minority of patients. New non-pharmacological alternatives like cellular cardiomyo-plasty or left ventricular (LV) implantable assist device are still under evaluation. So simpler and cheaper approaches have imperatively to be developed for treating this highly invalidated and rapidly growing and ageing population. Cardiac resynchronization therapy (CRT) with multisite biventricular pacing has been initiated in France in early 90's. The aim of CRT is to try and correct the electromechanical abnormalities that result from antrioventricular and intraventricular conduction delay (IVCD), a very common observation (30-50%) in patients with chronic heart failure (CHF). IVCD worsens progressively overtime and is responsible for discoordinated interventricular and left-intraventricular contraction-relaxation which in turn enhances the hemodynamic consequences of the baseline LV systolic dysfunction. This new therapeutic concept was first assessed in acute hemodynamic studies with temporary pacing, then in pilot studies with permanent transvenous biventricular pacing. Several controlled studies (MUSTIC, MIRACLE, CONTAKCD...) were conducted afterwards and demonstrated that CRT might improve significantly symptoms, quality of life and exercise tolerance in patients with severe heart failure (NYHA class III -- IV) under optimized drug treatment, low ejection fraction and significant IVCD as indicated by an intrinsic QRS duration QRS150 MS. The rehospitalization rate was also significantly reduced with CRT. The clinical benefit was preserved over at least 1 year follow-up. The first validation stem is now completed. There are however several important questions yet to be answered. Which is the impact of CRT on all-cause mortality and sudden cardiac death? Two large-scale studies, CARE-HF in Europe and COMPANION in USA, are ongoing to try and answer this question. Which type of implantable devices has to be developed preferentially: multisite pacemakers or multisite pacemaker-defibrillators? May CRT induce LV reverse remodelling and thus help at preventing heart failure progression? Which cost-effectiveness ratio for heart faulure management? How to better select potential responders?... The whole validation process of CRT should be completed on 2004-2005.

The case of a 13-year-old child with an unusually localized "focal" permanent atrial tachycardia is reported. Electrophysiologic study showed that the earliest atrial activation occurred in the distal coronary sinus and preceded the atrial depolarization recorded along the endocardial side of the lateral part of the mitral annulus. Distal coronary sinus mapping revealed a fragmented, polyphasic atrial electrogram. Radiofrequency current delivery to the site permanently stopped the tachycardia.

In light of evolving pacemaker technology and increasing interest in multisite pacing, the Committee on the Development of Position Statements (CDPS) of the North American Society of Pacing and Electrophysiology (NASPE) created an ad hoc Pacemaker Mode Code Task Force in April 2001 under the chairmanship of David L. Hayes, MD, for the purpose of bringing the NASPE/British Pacing and Electrophysiology Group (BPEG) Generic Pacemaker Code (NBG Code) up to date. The task force, whose members are the authors of this article, designed a revised NBG Code in which three major issues were taken into account. First, it was recognized that all modern pacemakerpulse generators are capable of extensive bidirectional communication with an external programming device, making them "communicating" pulse generators as defined by the current (1987) NBG Code. Second, it was decided that a means of providing basic information regarding the location of multisite pacing would be a useful ingredient of the NBG Code. Third, in view of the extensive antibradycardia pacing capabilities common in modern implantable cardioverter defibrillators and the availability of the NASPE/BPEG Defibrillator Code (NBD Code), it was considered unnecessary for the NBG Code to address the presence or absence of antitachycardia features. The resulting updated version of the NBG Code as described herein was endorsed by the BPEG on September 20, 2001 and adopted by the NASPE Board of Trustees on October 18, 2001. The structure of the revised NBG Code differs from that of the previous version in two respects alone: Position IV specifies only the presence or absence of rate modulation, and Position V specifies only the location or absence of multisite pacing (i.e., biatrial or biventricular pacing with at least two stimulation sites in each case) more than one stimulation site in any single cardiac chamber, or any combination of these. The revised NBG Code is deliberately configured to avoid confusion with earlier mode codes, and it is the authors' hope that it will serve as an enhanced resource for communication among those engaged in every phase of the multidisciplinary practice of cardiac rhythm management.

BACKGROUND—Biventricular pacing has been proposed as an adjuvant to optimal medical treatment in patients with drug refractory heart failure caused by chronic left ventricular systolic dysfunction and intraventricular conduction delay. OBJECTIVE—To assess the technical feasibility and long term results (over six years) of transverse left ventricular pacing with the lead inserted into a tributary vein of the coronary sinus. SUBJECTS—From August 1994 to February 2000, left ventricular lead implantation was attempted in 116 patients who were eligible for biventricular pacing (mean (SD) age 67 (9) years, New York Heart Association (NYHA) functional class III/IV, left ventricular ejection fraction 22 (6)%, QRS duration 185 (26) ms). RESULTS—The overall implantation success rate was 88% (n = 102). A learning curve was indicated by a progressive increase in success from 61% early on to 98% in the last year. The mean pacing threshold was 1.1 (0.7) V/0.5 ms at the time of implantation and increased slightly up to 1.9 (0.9) V/0.5 ms at the end of the follow up period (15 (13) months). The rate of acute and delayed left ventricular lead dislodgement decreased from 30% in the early years to 11% after 1999. During follow up, 19 patients required reoperation for delayed lead dislodgement or increase in left ventricular pacing threshold (n = 15), phrenic nerve stimulation (n = 3), or infection (n = 3). CONCLUSIONS—Transverse left ventricular pacing through the coronary sinus is feasible and safe. The rate of implantation failure and of lead related problems has decreased greatly with increasing experience and with improvements in the equipment. Keywords: biventricular pacing; left ventricular pacing; heart failure; intraventricular conduction delay

ObjectiveMono-centric observation of microbiological specificities and prognostic factors in cardiac device-related infective endocarditis (CDIE).MethodsReview of 86 cases of certain CDIE gathered from 2000 to 2008, diagnosed on blood culture (77%) or lead tips culture (75%) and associated with evidence of vegetation on leads or on right heart endocardium.ResultsThe infection was attributed to a coagulase-negative staphylococci (CNS) in 47% of the cohort; Staphylococcus aureus (SA) in 28%, the other gram-positive cocci in 13%, the gram-negative in 9% and gram-positive bacilli in 3%.CNS was associated with less left cardiac valves septic localisations (p=0,013) and with a better survival as compared to the other germs (p=0,013). The multivariate analysis looking for predictive factors for 1-year mortality conclude to a positive correlation with:–COPD (chronic obstructive pulmonary disease) (aOR, 1.23; 95% CI, 1.33 to 9.85; p=0.01),–Infections to a “non-CNS”; germ (aOR, 1.65; 95% CI, 1.50 to 18.22, p=0.009).Compared with an ‘historic’ reference series including 50 CDIE from 1992 to 1999, no significant microbiology evolution has been demonstrated (p=0.64) When compared prior to 2000 to following years, the patient's characteristics changed. The aging (p=0.01) and the severity of the cardiac disease (p