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Summary Background The relationship between electrical and mechanical indices of cardiac dyssynchronization in systolic heart failure (HF) remains poorly understood. Objectives We examined retrospectively this relationship by using the daily practice tools in cardiology in recipients of cardiac resynchronization therapy (CRT) systems. Methods We studied 119 consecutive patients in sinus rhythm and QRS ≥ 120 ms (mean: 160 ± 17 ms) undergoing CRT device implantation. P wave duration, PR, e PR (end of P wave to QRS onset), QT, RR–QT, JT and QRS axis and morphology were putative predictors of atrioventricular (diastolic filling time [DFT]/RR), interventricular mechanical dyssynchrony (IVMD) and left intraventricular mechanical dyssynchrony (left ventricular pre-ejection interval [PEI] and other measures) assessed by transthoracic echocardiography (TTE). Correlations between TTE and electrocardiographic measurements were examined by linear regression. Results Statistically significant but relatively weak correlations were found between heart rate ( r = −0.5), JT ( r = 0.3), QT ( r = 0.3), RR–QT intervals ( r = 0.5) and DFT/RR, though not with PR and QRS intervals. Weak correlations were found between: (a) QRS ( r = 0.3) and QT interval ( r = 0.3) and (b) IVMD > 40 ms; and between (a) e PR ( r = −0.2), QRS ( r = 0.4), QT interval ( r = 0.3) and (b) LVPEI, though not with other indices of intraventricular dyssynchrony. Conclusions The correlations between electrical and the evaluated mechanical indices of cardiac dyssynchrony were generally weak in heart failure candidates for CRT. These data may help to explain the discordance between electrocardiographic and echocardiographic criteria of ventricular dyssynchrony in predicting the effect of CRT.

Background Cardiac resynchronization therapy (CRT) improves left ventricular (LV) function and induces LV remodeling, and it is an established therapy for advanced heart failure with prolonged QRS duration. One third of patients will not benefit from this invasive therapy. Objective The purpose of this study was to evaluate whether left atrial (LA) strain imaging (e) parameters could help in predicting the response in terms of LV reverse remodeling after CRT. Methods A total of 79 patients who underwent CRT were evaluated with echography before implantation. LA function and LV function were assessed with M-mode, 2-dimensional echocardiography, Doppler, tissue Doppler velocity, and e. LV reverse remodeling was defined as a >15% reduction in LV end-systolic volume. Results At 6 months, 54 patients (68%) were responders to CRT. In multivariable logistic regression, LA systolic peak of strain rate (SRA) (odds ratio [OR} 10.5, 95% confidence interval [CI] 1.76–62.1, P = .01), left bundle branch block (OR 6.8, 95% CI 1.06–43.9, P = .04), ischemic cardiomyopathy (OR 3.93, 95% CI 1.07–14.4, P = .04), and LV preejection index (OR 1.03, 95% CI 1.01–1.05, P = .01) were associated with CRT response. With an SRA cutoff of –0.75%, the negative predictive value for predicting CRT response was 0.62. Conclusion This study demonstrated the possible relevance of assessing LA function before CRT. SRA appeared to be a good predictor of CRT response. Integrating this LA function analysis into the multivariable assessment of patient candidates for CRT should be considered.

Summary Background The rate of pacemaker implantation is rising. Given that the life expectancy of the population is projected to increase, a large number of elderly patients are likely to be implanted in the future. As pacemaker batteries can last for 8–10 years, an increasing number of pacemaker recipients will require replacement of their devices when they become nonagenarians. Aims To analyse the short- and long-term outcomes after device replacement in nonagenarians. Methods Patients aged ≥ 90 years referred to a tertiary centre for pacemaker replacement from January 2004 to July 2014 were included retrospectively. Clinical follow-up data were obtained from clinical visits or telephone interviews with patients or their families. The primary clinical endpoint was total mortality. Secondary endpoints included early and delayed procedure-related complications and predictive risk factors for total mortality. Results Sixty-two patients were included (mean age 93.3 ± 2.9 years at time of pacemaker replacement). Mean procedure duration was 35.7 ± 17.2 minutes. Mean hospital stay was 2.2 ± 1.1 days. One patient died from a perioperative complication. Thirty-seven patients (59.7%) died during a median follow-up of 22.1 months (interquartile range, 11.8–39.8 months). Survival rates were 84.2% (95% confidence interval [CI] 71.8–91.5%) at 1 year, 66.9% (95% CI 51.8–78.2%) at 2 years and 22.7% (95% CI 10.6–37.7%) at 5 years. Atrial fibrillation (hazard ratio 2.47, 95% CI 1.1–5.6) and non-physiological pacing (i.e. VVI pacing in patients in sinus rhythm) (hazard ratio 2.20, 95% CI 1.0–4.9) were predictors of mortality. Conclusions Pacemaker replacement in nonagenarians is a safe and straightforward procedure. These data suggest that procedures can be performed securely in this old and frail population, with patients living for a median of 30 months afterwards.

International audience; Background Rest echocardiography plays a role in the diagnosis and risk stratification of hypertrophic cardiomyopathy (HCM). Indeed, left atrial enlargement, severe left ventricle (LV) hypertrophy and rest LV outflow tract (LVOT) gradients ≥50mmHg are sudden cardiac death risk factors as highlighted in recent guidelines. Conversely, exercise echocardiography findings play only a limited role in prognosis evaluations. Therefore, we sought to determine whether exercise induced changes in myocardial and valvular functions could improve HCM risk stratification. Methods and results Consecutive HCM patients with a preserved LV ejection fraction underwent standardized exercise echocardiography (including the assessment of myocardial function, dynamic left intra-ventricular gradient and valvular regurgitations) at baseline and were clinically followed for a median of 29.3 months. The primary endpoint was a composite criterion that included death from any cause, cardiorespiratory arrest, and hospitalization for a cardiovascular event. A total of 126 patients were included. Eighteen patients reached the primary endpoint. According to univariate Cox regression analysis, exercise LVOT gradient ≥50mmHg (HR=3.31, p=0.01) and significant (≥2/4) exercise mitral regurgitation (HR=3.64, p

International audience; Aims Rest echocardiography plays a role in hypertrophic cardiomyopathy (HCM) diagnosis and risk stratification because left atrial enlargement, severe left ventricle (LV) hypertrophy, and rest LV outflow tract (LVOT) gradients ≥50 mmHg are sudden cardiac death risk factors that have been highlighted in recent guidelines. Conversely, the lack of evidence makes that exercise-echocardiography findings play a limited role. In clinical practice, LVOT gradient, but also mitral regurgitation (MR) or pulmonary pressure, seems relevant parameters to look for, during the exercise. Therefore, we sought to determine whether exercise-induced changes in myocardial and valvular functions could improve HCM risk stratification. Methods and results Consecutive primitive HCM patients with a preserved LV ejection fraction underwent standardized exercise echocardiography (including the assessment of myocardial function, dynamic left intraventricular gradient, and valvular regurgitations) at baseline and were clinically followed for a median of 29.3 months. The primary endpoint was a composite criterion that included death from any cause, cardiorespiratory arrest, and hospitalization for a cardiovascular event. A total of 126 patients were included. Eighteen patients reached the primary endpoint. According to univariate Cox regression analysis, exercise LVOT gradient ≥50 mmHg [hazard ratio (HR) = 3.31, P = 0.01] and significant (≥2/4) exercise MR (HR = 3.64, P , 0.01) were associated with the primary endpoint. Patients with significant MR had significantly higher rest and exercise LVOT gradients (P= 0.001 and P= 0.001) and larger left atria volumes (P , 0.001). Conclusion Significant exercise-induced MR appears to significantly impact the prognoses of HCM patients, and it is also associated with higher LVOT rest and exercise gradients,. © The Author 2015.

Summary Background Pulmonary vein (PV) isolation, using cryoballoon or radiofrequency ablation, is the cornerstone therapy for symptomatic paroxysmal atrial fibrillation (AF) refractory to antiarrhythmic drugs. One-third of the patients have recurrences, mainly due to PV reconnections. Aims To describe the different locations of reconnection sites in patients who had previously undergone radiofrequency or cryoballoon ablation, and to compare the characteristics of the redo procedures in both instances. Methods Demographic data and characteristics of the initial ablation (cryoballoon or radiofrequency) were collected. Number and localization of reconduction gaps, and redo characteristics were reviewed. Results Seventy-four patients scheduled for a redo ablation of paroxysmal AF were included; 38 had been treated by radiofrequency ablation and 36 by cryoballoon ablation during the first procedure. For the initial ablation, procedural and fluoroscopy times were significantly shorter for cryoballoon ablation (147.8 ± 52.6 min vs. 226.6 ± 64.3 min [ P P = 0.005], respectively). Overall, an identical number of gaps was found during redo procedures of cryoballoon and radiofrequency ablations. However, a significantly higher number of gaps were located in the right superior PV for patients first ablated with radiofrequency (0.9 ± 1.0 vs. 0.5 ± 0.9; P = 0.009). Gap localization displayed different patterns. Although not significant, redo procedures of cryoballoon ablation were slightly shorter and needed shorter durations of radiofrequency to achieve PV isolation. Conclusions During redo procedures, gap localization pattern is different for patients first ablated with cryoballoon or radiofrequency ablation, and right superior PV reconnections occur more frequently after radiofrequency ablation. Redo ablation of a previous cryoballoon ablation appears to be easier.

Introduction The rate of pacemaker(PM) implantations is continuously growing. A large number of nonagenarian patients will be implanted in the future. We aimed at analyzing the outcome after PM implantation in the elderly. Methods Patients aged ≥90 yo referred for PM implantation from 2004 to 2014 were retrospectively included. The primary clinical endpoint was total mortality. Results 113 patients were included (92.6±2.1yo). Five patients (3.5%) had short-term device-related complications (3 pocket hematoma, 1 lead displacement, 1 hemothorax). During the follow-up, 48 patients (42.5%) died. Survival rates were 77.4% (95%CI:67.4-84.7%), 68.7% (95%CI:57.4-77.6%) and 36.4% (95%CI:23.3-49.7%) after 1, 2 and 5 years, respectively. Atrial fibrillation (OR 3.5,95%CI:1.6-7.2) and a cardiomyopathy (OR 2.3,95%CI:1.2-4.4) at the time of implantation were independent predictors of mortality. Conclusion PM implantation in nonagenarians is safe, with a low risk of procedural complications. Download : Download full-size image Figure: Survival for nonagenarians after PM implantation

International audience; The principal role of the left atrium (LA) is to modulate left ventricular filling and cardiovascular performance by functioning as (i) a reservoir for pulmonary venous return during ventricular systole, (ii) a conduit for pulmonary venous return during early ventricular diastole, and (iii) a booster pump that augments ventricular filling during late ventricular diastole. The interplay between these atrial functions and ventricular performance throughout the cardiac cycle is crucial in many pathophysiological conditions.1,2 However, in clinical practice, we do not really assess all of the components of LA function. In fact, quantification of LA function remains challenging. Calculating ejection fraction or atrial ejection force has occasionally been proposed as methods for quantifying LA function, but they are neither routinely used nor recommended in the literature.3 Standard recommendations in the literature propose using LA volume calculated from trans-thoracic 2D echocardiography orthogonal views.3,4 LA size correlates with both LA and left ventricular (LV) function and is a strong predictor of cardiovascular morbidity and death.5 The antero-posterior diameter, calculated with M-mode or 2D echocardiography, is no longer considered to adequately represent the true LA size. For these reasons, the ASE/EACVI joined paper3 …

International audience; To the Editor: We thank Margulescu et al for their letter. It provides us with a unique opportunity to emphasize a few points that are extremely important to keep in mind about estimation of left atrial (LA) performance in cardiac resynchronization therapy (CRT) candidates. First, the main result of our study is that “LA peak systolic strain rate might be useful in predicting response to CRT.” This is not surprising if we consider that (1) previous studies have shown that LA volumes and function can be influenced by CRT; (2) superresponders to CRT have greater improvement in LA function1, 2, 3 and 4; and (3) increasing relevance has been given to LA function in overall heart physiology.1, 2, 3 and 4 Second, Margulescu et al state that “concerns have been raised that LA deformation indices cannot discriminate intrinsic LA function from the influence of LV function.” We agree that, as for many other echocardiographic parameters, LA strain is influenced by preload and afterload, and is impacted by left ventricular (LV) function, particularly by LV descent during systole.5 However, we need to emphasize that it is impossible to perfectly assess the function of an isolated cardiac cavity using current in vivo imaging techniques. Many studies have shown that LA strain is a rapid and highly reproducible method for estimating LA function. 6 Moreover, impaired LA strain is associated with a greater degree of LA fibrosis and with poor prognosis in the general population and in patients with mitral disease, which supports a potentially wider use of LA strain in clinical practice. 7, 8 and 9 Third, Margulescu et al observe that the “predictive value of LA SR for CRT response was modest and similar to other echocardiographic indices that have not been found useful, and is not recommended in current guidelines for selecting CRT candidates.” However, the goal of the present study was to explore a hypothesis and not to change current guidelines.10 With respect to our results, authors and readers should acknowledge that it is always difficult to demonstrate that an imaging technique can impact patient prognosis, even when large perspective studies have been specifically designed to prove it.11 and 12 Further studies are needed to support the role of LA strain in predicting CRT response, but exploration of LA function in this field is full of promise!

International audience; Aims Systolic pulmonary artery pressure (sPAP) is a well-known outcome predictor in patients with valvular heart disease. Limited data are available regarding the evaluation of right ventricular (RV) performance, particularly in patients with aortic stenosis (AS). The aim of this study was to evaluate the prevalence, determinants, and prognostic significance of RV dysfunction in severe AS independently from the strategy of treatment chosen. Methods and results Two hundred patients (mean age: 79.9 ± 8.8 years) with severe AS underwent two-dimensional and speckle tracking echocardiography for the evaluation of left ventricular (LV) and RV functions, aortic valve gradients, and sPAP. A tricuspid annular plane systolic excursion (TAPSE) ≤17 mm defined RV dysfunction. RV dysfunction was detected in 48 patients (24%). At multivariable regression analysis, LV global longitudinal strain (r = −0.29, P = 0.001), mean aortic gradient (r = 0.25, P = 0.002), and LV ejection fraction (r = 0.18, P = 0.02) were well correlated with TAPSE. After a median 16-month follow-up, cardiovascular death occurred in 17 patients. At multivariate Cox regression analysis, biventricular dysfunction (TAPSE ≤17 mm and LVEF ≤50%) emerged as the strongest predictor of prognosis (hazard ratio 4.08, 95% confidence interval 1.36–12.22; P = 0.012). Conclusions RV dysfunction is common in AS patients, and this finding can likely be accounted for by the RV–LV interdependence. Given that biventricular function impairment was a strong predictor of mortality in our population, we suggest that RV dysfunction should be systematically looked for in AS patients

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