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Background Atrial arrhythmias (AAs) are frequent after lung transplantation (LT) and late postoperatively. Several predictive factors of early postoperative AAs after LT have been identified but those of late AAs remain unknown. Whether AA after LT affects mortality is still being debated. This study assessed in a large cohort of LT patients the incidence of AAs early and late after surgery, their predictive factors and their effect on mortality.Methods and Results:We studied 271 consecutive LT patients over 9 years. Mean follow-up was 2.9±2.4 years. 33% patients developed postoperative AAs. Age (odds ratio (OR) 2.35; confidence interval (CI) [1.31-4.24]; P=0.004) and chronic obstructive pulmonary disease (OR 2.13; CI [1.12-4.03]; P=0.02) were independent predictive factors of early AAs. Late AAs occurred 2.2±2.7 years after transplant in 8.8% of the patients. Pretransplant systolic pulmonary arterial pressure (PTsPAP) was the only independent predictive factor of late AA (OR 1.028; CI [1.001-1.056]; P=0.04). Double LT was associated with long-term freedom from atrial fibrillation (AF) but not from atrial flutter (AFL). Early and late AAs after surgery had no effect on mortality. Double LT was associated with better survival. Conclusions Early AA following LT is common in contrast with the low occurrence of late, often organized, AA. Early and late AAs do not affect mortality. PTsPAP is an independent predictor of late AA. Double LT protects against late AF but not AFL.

ObjectiveAtrial fibrillation (AF) is one of the most common side effects of ibrutinib, a drug that has dramatically improved the prognosis of chronic B-cell malignancies such as chronic lymphocytic leukaemia (CLL). The true incidence of ibrutinib-related AF (IRAF) is not well known and its therapeutic management poses unique challenges especially due to the inherent risk of bleeding. We aimed to determine the incidence and predictors of IRAF, and to analyse its management and outcome.MethodsA standardised monitoring was applied at two cardio-oncology clinics in consecutive patients referred before and during ibrutinib therapy. The primary endpoint was the incidence of IRAF. The excess of AF incidence with ibrutinib was studied by comparing the incidence of IRAF with the expected incidence of AF in general population and in patients with CLL not exposed to ibrutinib.Results53 patients were included. The incidence of IRAF was 38% at 2 years and the risk was 15-fold higher than the AF risk in both the general population and patients with CLL not exposed to ibrutinib (p2 at treatment initiation identified patients at high risk of developing IRAF. No major bleeding events occurred in patients on ibrutinib, although the majority of patients with IRAF were treated with anticoagulants.ConclusionsThis cardio-oncology study showed that the risk of IRAF was much higher than previously reported. The majority of cases occurred in asymptomatic patients justifying close monitoring.

International audience; Background Iron deficiency (ID) is common in heart failure (HF), and is associated with unfavourable clinical outcomes. Although it is recommended to screen for ID in HF, there is no clear consensus on the optimal timing of its assessment. Aim To analyse changes in iron status during a short-term follow-up in patients admitted for acute HF. Methods Iron status (serum ferritin concentration and transferrin saturation) was determined in 110 consecutive patients (median age: 81 years) admitted to a referral centre for acute HF, at three timepoints (admission, discharge and 1 month after discharge). ID was defined according to the guidelines. Results The prevalence rates of ID at admission, discharge and 1 month were, respectively, 75% (95% confidence interval [CI] 67–83%), 61% (95% CI: 52–70%), and 70% (95% CI: 61–79%) (P = 0.008). Changes in prevalence were significant between admission and discharge (P = 0.0018). Despite a similar ID prevalence at admission and 1 month (P = 0.34), iron status changed in 25% of patients. Between admission and discharge, variation in C-reactive protein correlated significantly with that of ferritin (ρ = 0.30; P = 0.001). Advanced age, anaemia, low ferritin concentration and low creatinine clearance were associated with the persistence of ID from admission to 1 month. Conclusions Iron status is dynamic in patients admitted for acute HF. Although ID was as frequent at admission as at 1 month after discharge, iron status varied in 25% of patients.; Contexte La carence martiale (CM) est fréquente dans l’insuffisance cardiaque (IC) et associée à un pronostic défavorable. Bien qu’il soit recommandé de la dépister au cours de l’IC, il n’existe pas de consensus quant au moment optimal de réalisation du bilan martial. Nous avons analysé l’évolution du bilan martial au cours du suivi à court terme de patients hospitalisés pour IC aiguë. Méthodes Un bilan martial (taux sérique de ferritine et coefficient de saturation de la transferrine) a été effectué chez 110 patients consécutifs (âge médian : 81 ans) admis pour IC aiguë dans un centre de référence à trois moments différents (admission, sortie et 1 mois après la sortie). La carence martiale était définie conformément aux guidelines. Résultats Les taux de prévalence de la CM à l’admission, à la sortie et à 1 mois étaient respectivement de 75 % (intervalle de confiance [IC] 95 %, 67 % 83 %), 61 % (IC : 95 %, 52 % 70 %) et 70 % (IC : 95 %, 61 % 79 %) (p = 0,008). Ces changements de prévalence étaient significatifs entre l’admission et la sortie (p = 0,0018). Malgré une prévalence de la CM similaire entre l’admission et 1 mois (p = 0,34), le bilan martial avait changé chez 25 % des patients. Entre l’admission et la sortie, la variation de la protéine C-réactive était significativement corrélée à celle de la ferritine (ρ = 0,30; p = 0,001). L’âge avancé, l’anémie, un faible taux de ferritine et la faible clairance de la créatinine étaient associés à la persistance de la CM entre l’admission et 1 mois. Conclusions Le bilan martial est dynamique chez les patients admis pour une IC aiguë. Bien que la CM soit aussi fréquente à l’admission qu’à 1 mois après la sortie, le bilan martial varie chez 25 % des patients.

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Summary Background Guidelines recommend careful screening and treatment of coronary artery disease (CAD) in heart failure with preserved or mid-range ejection fraction (HFpEF/HFmEF). Aim We aimed to determine the prevalence and characteristics of CAD using a prospective systematic coronary angiography approach. Methods A systematic coronary angiography protocol was applied in consecutive patients admitted for HFpEF/HFmEF during a 6-month period in a single centre. History of CAD and results of angiography, including revascularization, were reported. Results Of the 164 patients with HFpEF/HFmEF who were included, an angiography assessment was applied in 108 (66%) (median age: 79 years [interquartile range: 70–85 years]; 54% were women). In our analysis, 64% (95% confidence interval [CI] 55–73%) of patients had a significant coronary stenosis corresponding to a global CAD prevalence of 80% (95% CI 73–88%). The prevalence of CAD was similar for HFpEF and HFmEF. The left main coronary artery presented a significant stenosis in 6.5% of cases and 39% of patients had a two- or three-vessel disease. The rate of significant coronary stenosis was non-significantly higher in patients with a history of CAD. Patients with HFpEF/HFmEF with and without CAD did not differ in clinically meaningful ways, in terms of symptoms or laboratory and echocardiography results. This strategy led to complete revascularization in 36% of patients with significant stenosis and in 23% of all patients with HFpEF/HFmEF. Conclusions Our study differs from others in that we used a systematic angiography approach. The results suggest a much higher prevalence of CAD in HFpEF/HFmEF than previously reported and should encourage clinicians to aggressively identify this co-morbidity.

Background. - An optimal maximum time of 60 minutes has been recommended in recent guide lines for the first evaluation and treatment of patients with acute heart failure (AHF); however, this has not been tested prospectively. Aim. - To analyze the impact of a time-to-treatment (TTT) strategy of < 60 minutes on the in-hospital outcome of patients with AHF. Methods. - During a single 1-month period, we consecutively enrolled all patients hospitalized with AHF in a prospective cohort. In this pilot study, TTT was defined as the time between the first medical contact to the onset of the first medical intervention. The primary outcome was a composite including in-hospital death or worsening AHF. Results. - Of the 74 patients included, 23 (31%) had a TTT of < 60 minutes. Although these patients were more likely to have a more severe episode of AHF, the primary outcome occurred only in patients with a TTT of >= 60 minutes. The primary outcome was significantly associated with a TTT of >= 60 minutes (P=0.036), low systolic blood pressure (P

International audience; Subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to transvenous ICD to prevent sudden cardiac death. Subcutaneous ICD implantation frequently requires general anesthesia because of procedure nociceptive steps during creation of a large device pocket and lead tunneling. This study aims to determine if a strategy of operator-guided controlled sedation with midazolam and analgesia with nalbuphine is effective in alleviating pain during S-ICD implantation. This prospective study included consecutive patients undergoing S-ICD implantation under controlled sedation with midazolam and combined analgesia with nalbuphine. The Critical-Care Pain Observation Tool (CPOT), a behavioral pain scale, was used for pain assessment during S-ICD placement and the Numeric Rate Scale (NRS) was used for evaluation of pain recollection after patient recovery. CPOT score of 3 or above and NRS score of 4 or above are considered to be associated with significant pain. Sixteen patients were included in this study: Ten men (62.5%) and six women with a mean age of 54 +/- 11 years. Indication for S-ICD implantation was primary prevention in 11 patients (68.8%). Mean dose of administrated midazolam and nalbuphine was 0.11 +/- 0.03 and 0.27 +/- 0.05 mg/kg, respectively. Mean CPOT during the whole procedure was 1.4 +/- 1.6. No patient presented procedural pain recollection as all 16 patients had NRS score less than 4. No serious adverse event related to sedation occurred during S-ICD implantation. This study suggests that operator-guided controlled sedation with midazolam and analgesia with nalbuphine is effective to alleviate procedural pain in patients undergoing S-ICD implantation and may constitute an alternative to general anesthesia.

Background Acute myocarditis is associated with cardiac arrhythmia in 25% of cases; a third of these arrhythmias are ventricular tachycardia (VT) or ventricular fibrillation (VF). The implantation of a cardiac defibrillator (ICD) following sustained ventricular arrhythmia remains controversial in these patients. Objectives We sought to assess the risk of major arrhythmic ventricular events (MAE) over time in patients implanted with an ICD following sustained VT/VF in the acute phase of myocarditis compared to those implanted for VT/VF occurring on myocarditis sequelae. Methods Our retrospective observational study included patients implanted with an ICD following VT/VF during acute myocarditis or VT/VF on myocarditis sequelae, from 2007 to 2017, in 15 French university hospitals. MAE was defined as any appropriate intervention of the defibrillator (antitachycardia pacing or shock) on VT/VF. Results Over a median follow-up period of 3 years, 11(39%) patients of the acute myocarditis group and 24(60%) patients of the myocarditis sequelae group experienced one or more MAE. Kaplan–Meier MAE rate estimates at one and three years follow-up were 19% and 45% in the acute group, and 43% and 64% in the sequelae group, respectively. There was no significant difference in the number or type of MAEs in the two groups. Conclusion Patients who experienced sustained ventricular arrhythmias during acute myocarditis had a very high risk of VT/VF recurrence during follow-up. These results challenge current guidelines for ICD implantation in acute myocarditis associated with VT/VF by showing that the risk of MAE recurrence remains high after the resolution of the acute episode.

International audience; The implantable cardioverter-defibrillator (ICD) is effective to prevent sudden cardiac death (SCD) in selected patients with heart disease known to be at high risk for ventricular arrhythmia. Nevertheless, this invasive and definitive therapy is not indicated in patients with potentially transient or reversible causes of sudden death, or in patients with temporary contra-indication for ICD placement. The wearable cardioverter defibrillator (WCD) is increasingly used for SCD prevention both in patients awaiting ICD implantation or with an estimated high risk of ventricular arrhythmia though to be transient. We conducted a review of current clinical uses and benefits of the WCD, and described its technical aspects, limitations and perspectives.

International audience; Background: Cardiovascular toxicity has become a challenging issue during cancer therapy. Nonetheless, there is a lack of consensual guidelines for their management. We aimed to determine the current practices of oncologists regarding cardiovascular toxicity related to anthracyclines, trastuzumab and angiogenic inhibitors and to gather their opinions on the development of cardio-oncology programs. Methods: A cross-sectional declarative study was submitted to French oncologists in the form of an individual, structured questionnaire. Results: A total of 303 oncologists responded to the survey. Ninety-nine percent of oncologists prescribed cardiotoxic therapies, including anthracyclines (83%), trastuzumab (51%) and other angiogenic inhibitors (64%). The method adopted for managing cardiovascular toxicity was based on guidelines from expert oncology societies for only 35% of oncologists. None was aware of recommendations from expert cardiology societies. Prescription of pre-, peri-and post-therapy cardiovascular assessment was inconsistent and significantly less frequent for all classes of angiogenic inhibitors than for anthracyclines and trastuzumab (P < 0.0001). Relative to pre-therapy assessment, post-therapy assessment was prescribed significantly less often for all cancer therapies (P < 0.0001). Attitudes regarding the onset of left ventricular dysfunction were much more inconsistent when angiogenic inhibitors were involved. Additionally, the management of hypertension and QT prolongation was also inconsistent. Finally, 88% of oncologists supported projects of cardio-oncology programs development. Conclusions: Practices of oncologists are disparate in the field of cardiovascular toxicity. This finding underlines the complexity of managing many different situations and the need for distribution of formal guidelines from oncology and cardiology expert societies. The development of personalized cardio-oncology programs seems essential. (C) 2017 Elsevier B.V. All rights reserved.

Immune checkpoint inhibitors (ICIs) represent a major advance in the treatment of cancer. Although clinical trials reported a low incidence of immune-related cardiovascular adverse events,1 the number of published life-threatening cases of cardiotoxicity is increasing.2 In this descriptive observational analysis, we aimed to describe the clinical manifestations, management, and outcomes of patients who developed ICI-related cardiotoxicity. The medical records of patients with a clinical suspicion of ICI-related cardiotoxicity were reviewed from the databases of 2 cardio-oncology units between March 2015 and April 2017. The patients are managed according to similar protocols. Because no specific follow-up had previously been established for patients receiving ICIs during the study period, the oncologists referred patients receiving ICIs only on the basis of their clinical suspicion of cardiovascular events. These patients had a standardized evaluation including clinical consultation, ECG, transthoracic echocardiography, and measurement of brain natriuretic peptide and troponin I serum levels. The management of cardiotoxicity was left to the physician’s discretion. The study was approved by our institutional review board, and informed consent has been obtained from the subjects. To create a pooled analysis, we also searched PubMed for English articles reporting cases of ICI-related cardiotoxicity until April 2017. We selected …

International audience; Cardiovascular toxicity is a potentially serious complication that can result from the use of various cancer therapies and can impact the short-and long-term prognosis of treated patients as well as cancer survivors. In addition to their potential acute cardiovascular adverse events, new treatments can lead to late toxicity even after their completion because patients who survive longer generally have an increased exposure to the cancer therapies combined to standard cardiovascular risk factors. These complications expose the patient to the risk of cardiovascular morbi-mortality, which makes managing cardiovascular toxicity a significant challenge. Cardio-oncology programs offer the opportunity to improve cardiovascular monitoring, safety, and management through a better understanding of the pathogenesis of toxicity and interdisciplinary collaborations. In this review, we address new challenges, perspectives, and research priorities in cancer therapy-related cardiovascular toxicity to identify strategies that could improve the overall prognosis and survival of cancer patients. We also focus our discussion on the contribution of cardio-oncology in each step of the development and use of cancer therapies. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Background The wearable cardioverter defibrillator (WCD) is a life-saving therapy in patients with high risk of arrhythmic death. We aimed to evaluate ventricular arrhythmia (VA) occurrence rate and compliance with the WCD during the first 90 days following myocardial revascularisation with percutaneous coronary intervention (PCI) in patients with left ventricular ejection fraction (LVEF) Methods From September 2015 to November 2016, clinical characteristics, WCD recordings and compliance data of the aforementioned subset of patients were prospectively collected. Results Twenty-four patients (men = 20, 80%) were included in this analysis. Mean age was 56 ± 10 years and mean LVEF at enrolment was 26.6 ± 4.3%. During a mean wearing period of 3.0 ± 1.3 months, two episodes of VA occurred in two patients (8.3%): one successfully treated with WCD shock and one with spontaneous termination. The mean and median daily use of the WCD was 21.5 hours and 23.5 hours a day, respectively. Eighteen patients (75%) wore the WCD more than 22 hours a day. Conclusions The rate of VA, during the WCD period use after myocardial revascularisation with PCI, was high in our study. Otherwise it underlined that patient compliance is critical during the WCD period use. Remote monitoring and patient education are keys to achieve good compliance.

Re-hospitalizations and deaths are particularly high during the first month following hospitalization for IC. Thus, several programs have been proposed in recent years, including the ‘Programme d’Accompagnement du Retour a Domicile(PRADO)’. The objectives of this program are to reduce the re-hospitalization and death of IC patients and to improve their quality of life. This is a monocentric observational retrospective study whose main objective was to evaluate the feeling of general practitioners,cardiologists and community nurses in the implementation of the PRADO IC program. The secondary objectives were to determine the impact of the program on the number of re-hospitalizations and deaths within 6 months following hospitalization. It was also to evaluate the feelings of the patients included.60 physicians and 36 community nurses participated in our study as well as 56 patients. The knowledge of the protocol concerned only 28% of general practitioners and 80% of cardiologists (significant difference between specialties). The majority of health professionals seem to favor this program. The 6-month re-hospitalization rate for IC was 21.6%. None of the triggering factors corresponded to a therapeutic break or a difference in diet, suggesting that the therapeutic education sessions of the program have borne fruit. An advanced age,outpatient BNP ≥ 400 pg/mL, and impaired LVEF were correlated with increased risk of re-hospitalization (no statistically significant link). We also found a trend toward shorter re-hospitalizations. Mortality at 6 months was 18.2%. Older age (> 85 years) was statistically associated with a higher risk of cardiovascular mortality. The majority of patients reported having felt a benefit to carry out this program, because it was accessible in its content and easy to set up at home. In conclusion, the low knowledge of the program should allow for new effective dissemination methods for this type of program as the prevalence of HF will continue to grow in the coming years.

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International audience; Although paroxysmal atrial fibrillation (AF) is known to be initiated by rapid firing of pulmonary veins (PV) and non-PV triggers, the crucial role of cardiac autonomic nervous system (ANS) in the initiation and maintenance of AF has long been appreciated in both experimental and clinical studies. The cardiac intrinsic ANS is composed of ganglionated plexi (GPs), located close to the left atrium-pulmonary vein junctions and a vast network of interconnecting neurons. Ablation strategies aiming for complete PV isolation (PVI) remain the cornerstone of AF ablation procedures. However, several observational studies and few randomized studies have suggested that GP ablation, as an adjunctive strategy, might achieve better clinical outcomes in patients undergoing radiofrequency-based PVI for both paroxysmal and nonparoxysmal AF. In these patients, vagal reactions (VR) such as vagally mediated bradycardia or asystole are thought to reflect intrinsic cardiac ANS modulation and/or denervation. Vagal reactions occurring during cryoballoon- (CB-) based PVI have been previously reported; however, little is known on resulting ANS modulation and/or prevalence and significance of vagal reactions during PVI with the CB technique. We conducted a review of prevalence, putative mechanisms, and significance of VR during CB-based PVI.

Introduction Atrial arrhythmias (AA) frequently occur after thoracic surgery, and are usually transient and benign. Strokes are a rare but serious neurological complication after lung transplantation. Although their incidence is now well known, their predictive factors remain uncertain. Objective The objective of this study was to evaluate the occurrence of postoperative AA in a cohort of lung transplanted patients and their relationship with the onset of stroke. Patients, materials and methods In total, 271 consecutive lung transplanted patients between 2005 and 2014 were retrospectively studied and followed during a mean of 3.2 ± 2.4 years. The data collected included clinical features, preoperative assessment, surgical reports and clinical follow-up. All arrhythmias recorded since the transplantation were analyzed. All strokes were collected. Results Thirty-three percent of patients presented AA in the immediate postoperative period. Fifteen patients (5.5%) presented stroke after transplantation, in 13 cases of ischemic origin. For 80%, stroke occurred within the first 6 months postoperatively. Mean CHA2DS2-VASc score was 1.1. Per- or postoperative low cardiac output was found as the only independent predictive factor of stroke onset [OR 4.6; CI (1.18–17.86); P = 0.027]. Postoperative AA and CHA2DS2-VASc score were not significantly associated with stroke. Postoperative AA did not affect in-house and long-term mortality. Conclusion AA are frequent after lung transplantation and don’t affect mortality. Neither AA nor CHA2DS2-VASc score are related to the occurrence of stroke. In contrast, a perioperative low cardiac output is an independent predictive factor of stroke after lung transplantation.

Background Atrial arrhythmias (AA) are observed frequently early after lung transplant and also late after the surgery. Several predictive factors of post-operative AA after lung transplant have been already identified whereas those of late AA are still not known. Whether AA after lung transplant impacts mortality and the optimal strategy of rhythm management are still debated. The Purpose of the study was to assess in a large cohort of lung transplanted patients the incidence of AA early and late after surgery, their predictive factors and their impact on mortality. Methods and results We included 271 consecutive patients single or double lung-transplanted over a 9-years period in a large French center. We collected baseline clinical, surgery and post-operative data. The follow-up was 2,9±2,4 years. 33% patients developed post-operative AA. Age (HR=2,35; CI [1,31-4,24]) and chronic obstructive pulmonary disease (HR=1,028; CI [1,12-4,03]) were independant predictive factors of post-operative AA. Late AA occurred 2,2±2,7 years after transplant in 8.8% of the patients. Systolic pulmonary arterial pressure was the only independent predictive factor of late AA (HR=1,028; CI [1,001; 1,056]). Double lung transplant was associated with long term freedom from AF compared with single transplant (p=0,05) whereas the Kaplan-Meier curve for the development of late atrial flutter was similar in single and double lung transplant. Early and late AA after surgery showed no impact on mortality. Bilateral lung transplant was associated with a better survival. Conclusion Post-operative AA after lung transplantation are common with good outcome and contrast with the low occurrence of late organized AA. Double lung transplantation protects against AF but not AFL. Underlying electrophysiological mechanisms may explain these observations. Predictive factors of early and late AA after transplantation are different. Nevertheless these AA do not impact mortality after lung transplant (figure next page). Download : Download high-res image (108KB) Download : Download full-size image Abstract 0376 – Figure: Survival free of late AF and AFL by transplant