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A 20-year-old patient is admitted to the emergency room for chest pain occurring in the context of recurrent left complete pneumothorax. Ultrasensitive troponinemia is elevated to 20 times normal. Myocardial distress is attributed to pneumothorax following the negativity of cardiological examinations (EKG, TTE, cardiac MRI). The pneumothorax is drained with a favorable evolution. This is the first reported case of pneumothorax associated with a significant elevation of troponin without ECG change, TakoTsubo syndrome, or myocardial inflammation. Several mechanisms are considered: rotation of the myocardium around its axis, increase in pulmonary vascular resistance with overload of right ventricular pressure, disturbance of coronary blood flow on significant mediastinal compression with decrease in systolo-diastolic myocardial perfusion.

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

Cas clinique Il s’agit d’un patient âge de 46 ans admis en cardiologie pour suspicion d’embolie pulmonaire devant l’apparition brutale d’une dyspnee associee a une elevation du taux de Dimeres en ville. A l’admission, le patient est tachycarde sans desaturation. Une anticoagulation efficace est initiee. Le diagnostic d’embolie pulmonaire est confirme a l’angioscanner. L’echographie cardiaque transthoracique ne retrouve pas d’element en faveur d’un cœur pulmonaire aigu mais revele la presence d’un thrombus intra ventriculaire droit associe a un comblement apical des apex VD et VG. Une IRM est realisee et retrouve un aspect typique d’endocardite de Loeffler. La numeration formule sanguine met en evidence une hypereosinophilie. On effectue des prelevements a la recherche d’une infection parasitaire et un myelogramme a la recherche d’une hemopathie. Les prelevements ne retrouvent pas d’infection parasitaire. L’etude du myelogramme oriente vers un syndrome hypereosinophilique. L’analyse par biologie moleculaire met en evidence un transcrit de fusion FIP1L1-PDGFRA en faveur d’un syndrome hypereosinophilique primitif. Un traitement par inhibiteur des proteines kinases est initie. Apres une semaine de traitement, l’hypereosinophilie a regressee. Un mois plus tard, l’echographie et l’IRM se sont quasiment normalisees. Conclusion Ce cas clinique d’endocardite de Loffler revelee par une complication cardioemboligene permet d’aborder une etiologie rare de cette pathologie : le syndrome hypereosinophilique primitif.

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.

Background— Electromyography-guided phrenic nerve (PN) monitoring using a catheter positioned in a hepatic vein can aid in preventing phrenic nerve palsy (PNP) during cryoballoon ablation for atrial fibrillation. We wanted to evaluate the feasibility and efficacy of PN monitoring during procedures using second-generation cryoballoons. Methods and Results— This study included 140 patients (43 women) in whom pulmonary vein isolation was performed using a second-generation cryoballoon. Electromyography-guided PN monitoring was performed by pacing the right PN at 60 per minute and recording diaphragmatic compound motor action potential (CMAP) via a quadripolar catheter positioned in a hepatic vein. If a 30% decrease in CMAP amplitude was observed, cryoapplication was discontinued with forced deflation to avoid a PNP. Monitoring was unfeasible in 8 of 140 patients (5.7%), PNP occurred in 1. Stable CMAP amplitudes were achieved before ablation in 132 of 140 patients (94.3%). In 18 of 132 patients (13.6%), a 30% decrease in CMAP amplitude occurred and cryoablation was discontinued. Each time, recovery of CMAP amplitude took Conclusions— Electromyography-guided PN monitoring using a catheter positioned in a hepatic vein seems feasible and effective to prevent PNP during cryoballoon ablation using second-generation cryoballoon.

Contexte : la connaissance du traitement par les patients est un élément fondamental pour améliorer l’observance de celui-ci, notamment dans les maladies chroniques comme le syndrome coronarien chronique.Objectif : l’objectif principal était d’évaluer la compréhension des traitements cardiovasculaires des patients coronariens suivis en cabinet de médecine générale.Matériel et méthodes : nous avons inclus rétrospectivement des patients consultant au cabinet de médecine générale des « Bessillons » sur une période de 3 mois. Ils ont été convoqués pour remplir un questionnaire de 18 questions et un tableau concernant leur traitement de fond. Ils portaient sur leur vie socio-professionnelle, leur comorbidité, leur suivi médical et les caractéristiques de chacun de leur médicament (nom, rôle, tolérance clinique, durée et fréquence de prise). Le critère de jugement principal était le taux de compréhension global du traitement. Les déterminants de la connaissance ont été recherchés par analyse univariée et multivariée.Résultats : 60 patients ont été inclus. On retrouve 66.7% de bonne compréhension chez les patients. Les patients qui présentaient un meilleur profil étaient les femmes (92.3% - p=0.027), les patients ayant fait des études supérieures (82.4% – p=0.105), les patients âgés de > 55ans (70.4% - p=0.366), les patients avec ≤ 3 médicaments autres que cardiologiques (71% - p=0.465), et une prise de traitement depuis ≥ 5 ans.Conclusion : les patients coronariens avaient plutôt une bonne connaissance de leurs traitements cardiovasculaires. Une étude de plus grande ampleur semble nécessaire pour conforter ces résultats en augmentant la puissance de l’étude.