Search

International audience; Background Left atrial appendage occlusion (LAAO) is increasingly used for stroke prevention in patients with atrial fibrillation who are considered unsuitable for a lifelong oral anticoagulant regimen. Recently, a single-centre study reported device-related thrombus formation in 16.7% of patients treated with the second-generation Amulet device (St. Jude Medical, St. Paul, MN, USA), presenting a potential major safety concern. As "real-world" data on device-related thrombus formation following LAAO with the Amulet occluder are scarce, we aimed to evaluate this outcome in a retrospective registry.Methods Clinical and tranosesophageal echocardiography data after LAAO with the Amulet in consecutive patients from three centres were collated.Results Among 38 patients (mean age 75.8 years), mean (standard deviation) CHA(2)DS(2)-VASc and HAS-BLED scores were 4.4 (1.2) and 3.4 (0.9), respectively. All patients underwent successful device placement without procedure-related adverse events. The antithrombotic regimen at discharge consisted of dual antiplatelet therapy (DAPT) in 27 patients (71.1%), single antiplatelet therapy in 10 patients (26.3%), and no antithrombotic therapy in one patient (2.6%). Device-related thrombus was observed in one patient (2.6%) despite DAFT regimen. The outcome of this patient was uncomplicated after adjustment of oral anticoagulant therapy. No patients presented with a thromboembolic event following LAAO during a mean (standard deviation) follow-up of 15 (5) months.Conclusions In this retrospective study, device-related thrombus formation with the second-generation Amulet device was rare and occurred at a rate similar to that of the previous device. Importantly, no patient experienced a device-related thromboembolic event during follow-up. Larger real-life studies are required to confirm the safety profile of this increasingly used device.

BackgroundMyocarditis is a rare but life-threatening adverse event of cancer treatments with immune checkpoint inhibitors (ICIs). Recent guidelines recommend the use of high doses of corticosteroids as a first-line treatment, followed by intensified immunosuppressive therapy (IIST) in the case of unfavorable evolution. However, this strategy is empirical, and no studies have specifically addressed this issue. Therefore, we aimed to investigate and compare the clinical course, management and outcome of ICI-induced myocarditis patients requiring or not requiring IIST.MethodsThis case–control study included all patients consecutively admitted to The Mediterranean University Center of Cardio-Oncology (Aix-Marseille University, France) for the diagnosis of ICI-induced myocarditis according to Bonaca’s criteria and treated with or without IIST. In addition, we searched PubMed and included patients from previously published case reports treated with IIST in the analysis. The clinical, biological, imaging, treatment, all-cause death and cardiovascular death data of patients who required IIST were compared with those of patients who did not.ResultsA total of 60 patients (69±12 years) were included (36 were treated with IIST and 24 were not). Patients requiring IIST were more likely to have received a combination of ICIs (39% vs 8%, p=0.01), and developed the first symptoms/signs of myocarditis earlier after the onset of ICI therapy (median, 18 days vs 60 days, p=0.002). They had a significantly higher prevalence of sustained ventricular arrhythmia, complete atrioventricular block, cardiogenic shock and troponin elevation. Moreover, they were more likely to have other immune-related adverse events simultaneously (pConclusionThe need for IIST was more common in patients who developed myocarditis very early after the start of ICI therapy, as well as when hemodynamic/electrical instability or neuromuscular adverse events occurred. Treatment with infliximab might be associated with an increased risk of cardiovascular death.

Purpose Ablation of premature ventricular complexes (PVCs) originating from left-sided papillary muscles is challenging. We tested a new approach by performing high-density mapping of PVC. Methods and results We used a 20-pole deflectable spiral catheter during ablation procedures in four consecutive patients. Three presented with mitral valve prolapse, one with dilated cardiomyopathy. PVC burden was 24 ± 13%. The procedures lasted 182 ± 55.4 minutes, including 10 ± 3.2 minutes of radiofrequency. In all patients, mapping evidenced internal primary activation relative to the left ventricle shell (mean distance 21.3 ± 5.1 mm). Endocavitary prematurity was -38.3 ± 4.8 ms. Primary ablation success was achieved for all patients. Conclusions High-density mapping of the papillary muscles in the left ventricle using a spiral catheter may be feasible. We identified the PVC foci away from the left ventricular shell. This consolidates the assumption for the origin of these ectopic beats at the junction between the chordae tendineae and the papillary muscles.

Background Direct oral anticoagulants (DOACs) are first line therapy for stroke prevention in NVAF patients. They were reported to be as effective as vitamin K antagonists (VKA) for stroke prevention in high-risk NVAF patients, with lower bleeding events. Compared to VKA, there is no need of regular anticoagulation monitoring. Yet, we still estimate 2 to 5% of major bleedings (MB) and up to 15% of clinically relevant non-major bleedings (CRNMB). Purpose The goal of this study was to investigate specific anti-Xa activity (AXA) measurement as a mean to predict bleeding complications in NVAF patients. We also determined anti-Xa overdose risk factors. Methods We performed a prospective observational study from December 2016 to April 2020. We took blood samples on patients the day of inclusion to measure AXA. We considered as high responders, patients to whom AXA plasma levels were superior to the upper limit of the expected plasma level ranges from the European Heart Rhythm Association recommendations. MB, CRNMB from time to inclusion to April 2020 were collected. We then compared group of high responders and non-high responders. Results A total of 146 patients were analysed. Mean follow up was 20 months. Among them, 24 (16,4%) had MB or CRNMB during the follow up. 36 (24,6%) patients were high responders among which 10 had relevant bleedings. High responders showed a higher risk of bleeding in univariate analyses (P = 0.034). After adjustment in multivariate analyses, only HASBLED had an increased risk of bleeding with an OR of 2.88 (1.74–5.12); probably due to a small number of patients and short time of follow up. We also showed that women and concomitant use of amiodarone were responsible for increasing AXA plasma level. Conclusion AXA plasma level might be predictive of bleeding. Further studies with higher number of patients should be carried out to prove it. Female and amiodarone are both overdose risk factors.

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. We sought to assess the risk of major arrhythmic ventricular events (MAEs) 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. 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. Over a median follow-up period of 3 years, MAE occurred in 11 (39%) patients of the acute myocarditis group and 24 (60%) patients of the myocarditis sequelae group. Kaplan&ndash, Meier MAE rate estimates at one and three years of follow-up were 19% and 45% in the acute group, and 43% and 64% in the sequelae group. Patients who experienced sustained ventricular arrhythmias during acute myocarditis had a very high risk of VT/VF recurrence during follow-up. These results show that the risk of MAE recurrence remains high after resolution of the acute episode.

Acute heart failure (AHF) is a life-threatening medical emergency for which no new effective therapies have emerged in recent decades. No previous study has exhaustively described the entire course of care of AHF patients from first medical contact to hospital discharge or assessed its impact on prognosis., To fully describe the course of care and analyze its influence on outcomes in patients hospitalized with an AHF syndrome in an academic university center., One hundred and nineteen adults with AHF from three public academic university hospitals were consecutively enrolled in a multicenter prospective observational cohort study. All of the emergency departments, intensive care units, coronary care units, cardiology wards and other medical wards participated in the study., The composite primary outcome (6-month rate of cardiovascular death, readmission for acute heart failure, acute coronary syndrome or stroke) occurred in 59% of patients. This rate was high and similar regardless of first medical contact, type of transport, first medical department of admission and number of medical departments involved in the course of care. A cardiologist was involved in management in 80% of cases. The global median hospital stay was shorter with cardiology vs non-cardiology management (7 days [interquartile range 4-11] vs 10 days [interquartile range 7-18]; P=0.003). History of hypertension (P=0.004), need for non-invasive ventilation (P=0.023) and Lee prognostic score (P=0.028) were independently associated with the primary outcome., Morbimortality and readmissions were high regardless of the course of care in patients admitted for AHF in real life. The reduction in hospital stay when cardiologists were involved in management encourages the creation of "mobile AHF cardiology teams".

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.

International audience; Introduction: Anticoagulant therapy is critical to prevent ischemic recurrences and complications in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Unfractionated heparin (UFH), an injectable anticoagulant has several limitations: lack of predictability of its biological efficacy, platelets activation, heparin-induced thrombopenia and bleedings. Bivalirudin, a synthetic direct thrombin inhibitor has biological properties that promised better clinical outcome in ACS patients undergoing PCI. Areas covered: The present review aimed to summarize two decades of randomized clinical trials that compared bivalirudin to UFH in ACS patients treated with PCI. Early trials highlighted a reduction of bleedings with bivalirudin compared to UFH in combination with glycoprotein inhibitors (GPI). Recent studies questioned this reduction given that GPI are less and less used during PCI. Further, trials raised concerns about the risk of stent thrombosis in patients treated with bivalirudin. In light of this data, bivalirudin has been downgraded in international guidelines and appears as a second line anticoagulant agent after UFH. Expert opinion: The highly questioned reduction of bleedings under bivalirudin and the potential risk of stent thrombosis are unwarranted. Based on clinical trials, UFH has no equivalent in terms of anticoagulation in ACS patients undergoing PCI.

Infections of cardiac implantable electronic devices (CIEDs) have increased over the past decade. However, the impact of the climate on CIED infections is unknown. To determine whether there is a seasonal variation in CIED infections. In this single-center observational study, retrospective analysis of prospectively collected data was performed. Timone Hospital in Marseille (south-east France) is a tertiary care institution and the regional reference center for management of CIED infections. All consecutive patients with CIED extractions for infectious reasons were included over a 12-year period. We noted the mean temperature (°C), precipitation (mm) and the incidence of CIED infections over this period. Among 612 patients [mean (standard deviation) age, 72.4 (13.0) years; 74.0% male], 238 had endocarditis alone (38.9%), 249 had pocket infection alone (40.7%), and 125 had both (20.4%). We found bacterial documentation in 428 patients (70.0%), commensal in 245 (40.0%). The incidence of CIED infections was positively associated with high temperature (regression coefficient = 0.075; P = 0.01) and precipitation (regression coefficient = 0.022; P 0.01). Seasonal variation was specific of pocket infections, whether they were associated with endocarditis or not. Subgroups with infection seasonality were: women, elderly people ( 75 years), late CIED infection and skin commensal bacterial infections. We found a seasonal variation in pocket infections, whether associated with endocarditis or not. Infections were associated with elevated temperatures and precipitation. Therefore, specific prevention strategy should be discussed in high-risk patients.

Pulmonary vein isolation (PVI) using cryoballoon (CB) technique and cavotricuspid isthmus (CTI) ablation using radiofrequency (RF) are established interventions for drug-resistant atrial fibrillation (AF) and typical atrial flutter (AFL). Twelve patients with a mean age of 62 ± 12 years underwent simultaneous delivery of RF energy at the CTI during CB applications at the PV ostia. Pulmonary vein isolation was achieved in all PVs and sustained bidirectional CTI conduction block obtained in all patients. The reported ablation protocol of combined paroxysmal AF and typical AFL did not result in prolongation of the procedure duration or in prolonged radiation exposure when compared to CB-PVI alone. No interferences between both ablation energy systems were observed. These preliminary results suggest that combined paroxysmal AF and typical AFL can be successfully and safely ablated using hybrid energy sources with simultaneous CTI ablation using RF during CB applications at the PV ostia.

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 Pulmonary vein isolation (PVI) using cryoballoon (CB) catheter is a new technique for atrial fibrillation (AF) ablation. Previous studies used computer tomography (CT) or magnetic resonance imaging (MRI) scan to determine the pulmonary vein (PV) diameter and anatomy for choosing the CB size. We evaluated pre-ablation transoesophageal-echocardiography (TEE) as an alternative to CT/MRI scan in patients undergoing AF ablation for determining the appropriate size of the CB. Methods Fifty-five consecutive patients (men=43, women=12) with a mean age of 63±12.5years, and with drug-refractory paroxysmal AF (34 patients) or persistent AF (21 patients) were included in this prospective study. All patients underwent pre-ablation TEE. Results Hypertension was present in 19 patients (34%). Mean anterior–posterior left atrium diameter was 45.1±8.9mm. In total, 217 PV were targeted using a single 23-mm (n=14) or 28-mm (n=40) CB catheter chosen according to TEE-obtained measurements. PVI was achieved in 195 PV (90%). Mean number of CB applications per patient was 9.8±2.1 (range 8–14). Mean procedure duration and fluoroscopy times were 131±27min (90–190min) and 36±12min (22–66min) respectively. Phrenic nerve palsy occurred in 3 patients (5.4%) and was transient ( Conclusion This study suggests that TEE is an easily available and effective tool to select the size of the CB for PVI according to evaluated PV diameters and anatomy.

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.

Congress of the European-Society-of-Cardiology (ESC), Rome, ITALY, AUG 27-31, 2016; International audience; no abstract

Background The Achieve catheter (AC; Medtronic-CryoCath, Pointe-Claire, Canada) is a circular mapping catheter introduced through the lumen of the cryoballoon (CB) catheter which is safe and effective to both navigate the CB to the pulmonary veins (PV) and allow PV potential recording during PV cryoablation. The aim of this study was to evaluate the impact of the use of the AC on procedural outcomes. Methods Sixteen consecutive patients (14 men) underwent AC-guided PV isolation (PVI) for drug-refractory paroxysmal atrial fibrillation (AF; AC group). Clinical and procedural data of these patients were compared to those obtained from 16 consecutive patients who had undergone PVI for paroxysmal AF with the regular “single transseptal” approach (control group). Results Clinical characteristics of patients enrolled in both groups did not differ significantly. In the AC group, 64 PVs were targeted using a single 28-mm (n = 13) or 23-mm (n = 3) CB catheter with PVI achieved in 62 PVs (97%). In the control group, 66 PVs were targeted using a single 28-mm (n = 12) or 23-mm (n = 4) CB catheter with PVI achieved in 62 PVs (94%), (P = non-significant for CB size and PVI rate). Procedure duration and fluoroscopy time were significantly reduced in AC group compared to control group (96.6 ± 26 minutes vs 125.9 ± 25 minutes, P = 0.003 and 24.4 ± 10 minutes vs 32.6 ± 11 minutes, P = 0.04, respectively). Conclusion The use of the AC significantly reduced procedure duration and radiation exposure during PVI with the CB technique. (PACE 2013; 36:24–30)

Ventricular allorhythmia is an electrocardiogram feature leading to a pattern of "regularly irregular" arrhythmia mainly reported during non-life-threatening organized atrial tachycardia. We report the infrequent case of a patient presenting with ventricular allorhythmia during infarct-related ventricular tachycardia. The potential mechanisms of this tachycardia are discussed.

Summary Background Atrial flutter (AFL) and atrial fibrillation (AF) are “fellow-travellers”. AF may be a stable, “isolated” rhythm, a bridge between sinus rhythm and AF, or both arrhythmias can coexist. Whether the characteristics of isolated AFL are different from those of patients with AFL combined with AF is still unclear. Aim To compare the clinical characteristics of patients with isolated AFL to those of patients with AFL combined with AF, in a series of patients referred for AFL ablation. Methods Seventy-six consecutive patients (mean age 66.9 ± 12.2 years; 53 men) with a history of electrocardiogram-documented paroxysmal or persistent AFL, referred for catheter ablation, underwent clinical work-up including bidimensional echocardiogram. Patients were subdivided into group I (44 with isolated AFL) and group II (32 with AFL and a history of AF). Results Underlying heart disease was present in 62 patients (81.6%). Hypertension was the most common cardiac disorder (n = 44, 57.9%) and was more prevalent in group II than in group I (75.0% vs 45.5%; P = 0.01). Prevalence of prior cardiac surgery was higher in group I (22.7% vs 6.3%; P = 0.04). AFL was persistent in 35 group I patients and 17 group II patients (79.5% vs 53.1%; P = 0.01). Class I or III antiarrhythmic drug use was more frequent in group II (84.4% vs 45.5%; P = 0.001). Conclusion This study showed significant differences between patients with isolated AFL and those with AFL combined with AF, in the prevalence of underlying heart disease and the use of antiarrhythmic medication, which were higher when both atrial arrhythmias were combined. In turn, the history of cardiac surgery (including atriotomy), was more common in patients with isolated AFL than in those with AFL combined with AF.

Prasugrel and ticagrelor are potent P2Y12-ADP receptor antagonists which are superior to clopidogrel in acute coronary syndromes. To date no clinical trial directly compared these two drugs. Platelet reactivity correlates with ischemic and bleeding events in patients undergoing percutaneous coronary intervention. Recent pharmacological studies have observed a delayed onset of action of these two drugs in ST-segment elevation myocardial infarction (STEMI). We provide the first adequately powered pharmacological study comparing PR following ticagrelor and prasugrel loading dose (LD) in STEMI patients when the maximal biological effect is reached. In the present study, ticagrelor was associated with a lower rate of high on-treatment PR compared to prasugrel.

International audience

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.

Inappropriate sinus tachycardia (IST) is a syndrome characterized by a sinus tachycardia not related to a medical condition, to a physiological response, or to medication or drugs and associated with symptoms, often invalidating and altering the quality of life of affected patients. It occurs predominantly in adolescents and young adults, and in the female sex. The diagnosis requires a complete work-up in order to exclude other causes of sinus tachycardia and one or several additional tests: 24-h ECG ambulatory recordings, echocardiogram, exercise testing, and autonomous nervous system assessment. It should be differentiated from the postural orthostatic tachycardia syndrome, with which it shares a number of symptoms, and other supraventricular tachycardias originating in the high right atrium. An electrophysiological study should be considered in selected cases in order to differentiate IST from other supraventricular tachycardias. The mechanism is still unclear, and possible etiologies may include intrinsic abnormality of the sinus node, autonomic dysfunction, hypersensitivity of the sinus node to catecholamines, blunted vagal system, or a combination of the above. The authors emphasize the wide spectrum of clinical presentations and the need to better define the IST and the criteria required to ascertain its diagnosis.

Peri-procedural platelet reactivity (PR) inhibition is critical in patients undergoing percutaneous coronary intervention (PCI). High on-treatment PR (HTPR) was associated with recurrent ischemic events in acute coronary syndrome (ACS) patients undergoing PCI. We aimed to compare a strategy of clopidogrel loading dose-adjustment (CDA) according to PR monitoring with standard prasugrel therapy to reduce the rate of patients exhibiting HTPR.We enrolled 177 ACS patients in a prospective multicentre randomized trial comparing CDA according to PR monitoring and prasugrel therapy. The VASP index was used to measure PR and a VASP ≥ 50% defined HTPR. The primary endpoint of the study was the rate of HTPR on discharge.Baseline characteristics of the CDA group (n = 88) and of the prasugrel group (n = 89) were similar. CDA significantly reduced PR and the rate of HTPR compared to a single LD of clopidogrel (30.9 ± 13.9%; p0.0001 and 43 to 2.3%; p0.001, respectively). Following CDA the rate of patients with HTPR was significantly lower in the CDA group compared to the prasugrel group on discharge (2.3 vs 15.7%; p = 0.005). In addition fewer patients in the CDA group had a VASP16% on discharge (14.7 vs 50.5%; p0.0001).In the present study, PR monitoring was superior to standard prasugrel therapy to reduce the rate of HTPR in ACS patients. In addition such strategy reduced the number of patients with very low PR.

The 9-French 8-mm tip cryoablation catheter confers a high rate of acute slow pathway (SP) elimination and an acceptable short-term outcome in patients with atrioventricular nodal reentrant tachycardia (AVNRT). The aim of this study was to investigate the long-term outcome of patients treated with this electrode in this indication.Eighty-two patients (female = 52) with a mean age of 54.9 ± 17.7 years underwent SP elimination for typical AVNRT with the 8-mm tip cryocatheter in our institution between November 2009 to June 2012. Clinical and procedural characteristics were prospectively collected.Acute procedural success defined as AVNRT non-inducibility at the end of the procedure was obtained in 81/82 patients (98.7 %). Mean procedure duration and fluoroscopy time were 74.4 ± 28.7 min (range, 35-160 min) and 8.7 ± 5.3 min (range, 2-26 min), respectively. Mean number of energy applications was 4.0 ± 2.4 (range, 2-15). No permanent atrioventricular block was observed. Transient atrioventricular block occurred in 12 patients (14.6 %). Traumatic fast pathway conduction block occurred in one patient before cryoenergy delivery. Using an intention-to-treat analysis, 78 patients (95.1 %) remained free of AVNRT recurrence during a mean follow-up of 17.8 ± 9.3 months.This study confirmed that the 8-mm tip cryocatheter is both safe and highly effective for SP conduction elimination in patients with AVNRT and demonstrated a low recurrence rate during a long-term follow-up.

Dual antiplatelet therapy with aspirin and clopidogrel dramatically reduced the rate of major adverse cardiac events following percutaneous coronary intervention. Clopidogrel is a prodrug which requires a two-step hepatic biotransformation thanks to the cytochrome P450 (CYP450) enzyme system. Genetic polymorphism of CYP450 system (e.g., CYP2C19*2) responsible for altered clopidogrel metabolism is a major cause of high on-treatment platelet reactivity (HTPR), which translates into thrombotic events in stented patients. Studies demonstrated that HTPR could be overcome in poor metabolizers thanks to increased loading doses or maintenance doses of clopidogrel or with the use of more potent antiplatelet agents such as prasugrel. Other genetic polymorphisms have also been correlated with HTPR: ABCB1, ATP2B2, and TIAM2. Large-scale randomized trials with clinical endpoints remain necessary to determine the optimal antiplatelet therapy in patients carrying genetic polymorphism associated with HTPR and thrombotic events.

A man, living in France, complained about dyspnea and weakness for the last year. At admission, the electrocardiogram showed atrial fibrillation. Transthoracic echocardiographyandcardiacmagnetic resonance imaging revealed a rare case of massively calcified left ventricular endomyocardial fibrosis (EMF), resulting in an obliteration of the apex (Fig. 1A and B). Despite the severity of the calcification intruding the fibrosis, h

Commotio cordis (CC) is a well-known cause of sudden cardiac death mainly reported in young patients who are accidentally struck in the left precordium. Clinical spectrumof CC iswide but eventsmainly occurred during sports. We report the first case of a patient who suffered CC related cardiac arrest after being shot with the Flash-BallTM less-lethal weapon. During an intervention by a police patrol, officers encountered a man described as threatening and aggressive. Neutralization shot was attempted with the Flash-BallTM handgun to the required distance of 7 m according to the police officer. The man was struck over the left precordium by a rubber bullet, and collapsed to the ground within few seconds. A mobile intensive care unit was dispatched to the scene. Ten minutes after the call, the medical team arrived on field and found a pulse less 43 year-old man with asystole as initial cardiac rhythm. After 12 min of resuscitation, a return of spontaneous circulation occurred. However, the patient was unstable, with mean arterial pressure of 40 mm Hg. At this time, inotropic support was undertaken with adrenaline and dobutamine. Physical examination found a large contusion mark on the left precordium. Cardiac auscultation was normal. Twelve lead ECG showed sinus bradycardia with premature ventricular complex (Fig. 1). Pre-admission transthoracic echocardiography found global severe left ventricular hypokinesia and absence of pericardial or pleural effusion (Fig. 2). The patient was

Numerous unusual causes of atrioventricular block (AVB) with cardiac pacemaker implantation have been documented including cough, deglutition, or other vagally mediated mechanism. In spinal cord lesions, only high cervical spinal cord lesion has been reported as a cause of severe bradycardia. We report a case with not cervical but dorsal vertebral trauma and persistent paroxysmal AVB requiring cardiac pacemaker implantation.