Fabien Garnier

Congenital Complete Absence of the Left Pericardium: A Rare Cause of Chest Pain or Pseudo‐right Heart Overload

Congenital defects of the pericardium are rare and poorly known cardiac malformations. Most of them are left‐sided and asymptomatic and are usually incidentally diagnosed.

Prognosis of silent atrial fibrillation after acute myocardial infarction at 1-year follow-up

Background Silent atrial fibrillation (AF), assessed by continuous ECG monitoring (CEM), has recently been shown to be common in acute myocardial infarction (AMI), and associated with higher hospital mortality. However, the long-term prognosis is still unknown. We aimed to assess 1-year prognosis in patients experiencing silent AF in AMI. Methods All consecutive patients with AMI who were prospectively analysed by CEM during the first 48 h after admission and who survived at hospital discharge were included. Silent AF was defined as asymptomatic episodes lasting at least 30 s. Patients were followed up at 1 year for cardiovascular (CV) outcomes. Results Among the 737 patients analysed, 106 (14%) developed silent AF and 32 (4%) symptomatic AF. Compared with the no-AF group, patients with silent AF were markedly older (79 vs 62 years, p<0.001), more frequently hypertensive (71% vs 49%, p<0.001) and less likely to be smokers (23% vs 37%, p<0.001). Also, they were more likely to have impaired LVEF (50% vs 55%, p<0.001). Risk factors in patients with silent AF were similar to those in patients with symptomatic AF. However, a history of stroke or AF was less frequent in silent AF than in symptomatic-AF patients (10% vs 25% and 10% vs 38%, respectively). At 1 year, CV events including hospitalisation for heart failure (HF) and CV mortality were markedly higher in silent-AF patients than in no-AF patients (6.6% vs 1.3% and 5.7% vs 2.0%, p<0.001, respectively). Conclusions Our large prospective study showed for the first time that silent AF is associated with worse 1-year prognosis after AMI. Systematic screening and specific management should be investigated in order to improve outcomes of patients after AMI.

Usefulness and limitations of contractile reserve evaluation in patients with low-flow, low-gradient aortic stenosis eligible for cardiac resynchronization therapy

In low‐flow, low‐gradient aortic stenosis (LF/LG AS), the assessment of contractile reserve (CR) by dobutamine stress echocardiography (DSE) is recommended for risk stratification and treatment strategy. However, DSE may show limitations in cases of left ventricular dyssynchrony (LVD). The impact of LVD in LF/LG AS, and the feasibility of CRT in this setting have never been evaluated. We aimed to assess: (i) the proportion of LF/LG AS patients with LVD; (ii) the influence of LVD on CR at DSE; and (iii) the effects of CRT in these patients.

Incremental predictive value of mean platelet volume/platelet count ratio in in-hospital stroke after acute myocardial infarction

Abstract Stroke is a serious complication after acute myocardial infarction (AMI) and is associated with an increased risk of death. Though the pathophysiological mechanisms are not exactly known, increased inflammation and platelet reactivity could play an important role in the occurrence of stroke during AMI. We aimed to investigate the relationship between both mean platelet volume (MPV), a parameter of platelet function, and C-reactive protein (CRP) and the occurrence of in-hospital ischemic stroke (IHS) after AMI. Data were obtained from a French regional survey for AMI that included 5976 patients admitted to an intensive care unit (ICU) between 2001 and 2010. Patients were divided into two groups according to the occurrence of IHS. MPV, platelet count (PC), and CRP were routinely measured at admission to the ICU; 99 (1.6%) IHSs were recorded during hospitalization after admission for AMI. In multivariate analysis, IHS was independently associated with a history of stroke (OR: 1.99%, CI: 1.1–3.49, p = 0.01), impaired left ventricular ejection fraction <40% (OR: 1.88, 95% CI: 1.20–2.94, p = 0.006), impaired renal function (OR: 1.94, 95% CI: 1.27–2.95, p = 0.002), CRP > 10 mg/l (OR: 2.19, 95% CI: 1.44–3.33, p < 0.001), and MPV/PC ratio (OR: 1.04, 95% CI: 1.01–1.08, p = 0.023). Compared with the first to fourth quintiles, the last quintile of the MPV/PC ratio was associated with higher rates of IHS on survival curve analysis (p = 0.014). At hospital admission, a high MPV/PC ratio and a high level of CRP might help to identify patients at increased risk of IHS. Moreover, these results provide new insights into the potential role played by increased inflammation and platelet reactivity in the occurrence of stroke after AMI.

Impact of the dynamic and static component of the sport practiced for electrocardiogram analysis in screening athletes

To interpret the electrocardiogram (ECG) of athletes, the recommendations of the ESC and the Seattle criteria define type 1 peculiarities, those induced by training, and type 2, those not induced by training, to rule out cardiomyopathy. The specificity of the screening was improved by Sheikh who defined “Refined Criteria,” which includes a group of intermediate peculiarities. The aim of our study was to investigate the influence of static and dynamic components on the prevalence of different types of abnormalities. The ECGs of 1030 athletes performed during preparticipation screening were interpreted using these three classifications. Our work revealed 62/16%, 69/13%, and 71/7% of type 1 peculiarities and type 2 abnormalities for the ESC, Seattle, and Refined Criteria algorithms, respectively(P<.001). For type 2 abnormalities, three independent factors were found for the ESC and Seattle criteria: age, Afro‐Caribbean origin, and the dynamic component with, for the latter, an OR[95% CI] of 2.35[1.28‐4.33] (P=.006) and 1.90[1.03‐3.51] (P=.041), respectively. In contrast, only the Afro‐Caribbean origin was associated with type 2 abnormalities using the Refined Criteria: OR[95% CI] 2.67[1.60‐4.46] (P<.0001). The Refined Criteria classified more athletes in the type 1 category and fewer in the type 2 category compared with the ESC and Seattle algorithms. Contrary to previous studies, a high dynamic component was not associated with type 2 abnormalities when the Refined Criteria were used; only the Afro‐Caribbean origin remained associated. Further research is necessary to better understand adaptations with regard to duration and thus improve the modern criteria for ECG screening in athletes.

High rate of recurrence at long-term follow-up after new-onset atrial fibrillation during acute myocardial infarction

Aims Silent and symptomatic atrial fibrillation (AF) are common during acute myocardial infarction (AMI), and associated with higher in-hospital and 1-year mortality. Are silent and symptomatic AF associated with higher rates of AF recurrence after hospitalization for AMI? Methods and results All consecutive patients admitted for AMI between January 2012 and August 2015 were prospectively analysed by continuous electrocardiogram monitoring <48 h after admission. Silent AF was defined as asymptomatic episodes lasting at least 30 s. The population was divided into three groups: no-AF, silent AF, and symptomatic AF. Altogether, 1621 patients were included in the prospective study and discharged alive from hospital. After excluding those with previous AF, permanent AF since the AMI and coronary artery bypass grafting surgeries and those lost to follow-up, 1282 remained. During the AMI, 1058 patients (83%) had a persistent sinus rhythm (SR), 168 (13%) had silent AF, and 55 (4%) had symptomatic AF. After a median follow-up of 1037 days (interquartile range 583-1342), new AF episodes were recorded in 59 patients (6%) of the SR group, 21 (13%) in the silent AF group, and 13 (24%) in the symptomatic AF group (P < 0.001). After Cox multivariate analysis, AF during AMI, indexed left atrial volume, age, and creatinine at discharge were identified as independent risk factors of AF after AMI. Conclusion The results of our large-scale study suggest that patients experiencing paroxysmal new-onset AF (silent or symptomatic) during AMI are at higher risk of AF at follow-up. Our data raise the question of implementing anticoagulation therapy following these brief and often neglected episodes.

A left lateral accessory pathway unmasked by rivastigmine

A 75-year-old woman was referred for advice regarding surface electrocardiographic modifications after the initiation of rivastigmine. In our patient, the baseline ECGs appeared perfectly normal. However, the initiation of a cholinesterase inhibitor unmasked a left lateral accessory pathway that had never been diagnosed before. Although cholinesterase inhibitors are known to increase vagal tone, the PR interval was shortened after rivastigmine administration, thus excluding this hypothesis to explain the appearance of the accessory pathway. Therefore, we hypothesized that cholinesterase inhibitors may have increased conduction velocity in the accessory pathway or in the atria.

0556: Left atrial strain is a powerful predictor of pulmonary hypertension in patients with severe aortic stenosis

Background Pulmonary hypertension (PH) is one of the most powerful predictors of outcome in patients with severe aortic stenosis (AS). However, the mechanisms of PH occurring in the setting of AS are not fully understood. Methods We studied 60 consecutive AS patients referred for preoperative assessment. Echocardiographic measurement: left ventricular ejection fraction (LVEF), mass (iLVM), longitudinal systolic strain (LVS), mean aortic gradient (MAG), aortic valve area (AVA), mitral E/A and E/e’ ratios, TAPSE, tricuspid annulus S wave velocity, left atrial volume (iLAV), left atrial longitudinal end systolic strain using speckle tracking (LAS). Right heart catheterization (RHC) measurements: pulmonary artery pressures (s/d/mPAP), pulmonary capillary wedge pressure (PCWP). Results Patient age was 81±8 years. MAG was 45±16mmHg, AVA 0.74±0.2cm 2, LVEF 63±16% (range 24-87), LVS –16±4%, LAS-4C 17±8% and LAS-2C 18±9%. Intraobserver variability for LAS measurement was 6%, interobserver variability was 7%. RHC showed: sPAP 51±18mmHg (range 28-101), mPAP 32±11mmHg (range 15-60), PCWP 19±8mmHg. In univariate analysis, the following echo-cardiographic parameters were associated with pulmonary artery pressures: LVS, mitral E/A and E/e’ ratios, mitral E wave deceleration time, TAPSE, tricuspid regurgitant flow velocity (feasibility 72%), LAS 4-C (feasibility 100%), and LAS 2-C (feasibility 94%). In multivariate analysis, except for the tricuspid regurgitant velocity, only LAS was independently associated with sPAP (r=–0.68, p 55mmHg) with a sensitivity of 85% and a specificity of 78%. Conclusion LAS measured by speckle tracking analysis is a simple and reproducible parameter and is a strong predictor of PH in patients with severe AS. These results suggest the LA reservoir function is a critical determinant of sPAP in AS. The prognostic value of LA strain should be further assessed.

097 Effects of permanent left atrial pacing in patients with heart failure and preserved ejection fraction

Results: During the study period, 21 patients (15 males) aged between 18 and 40 years old (mean age 33.1±5.6, range 18-39 years) underwent ASA. Among them, 76% were treated with beta-blockers, 33% calcium-channel antagonists and 5% disopyramide. There were 6 patients (29%) with prior pacemaker, 1 patient (5%) with history of sudden death and prior implantable cardioverter-defibrillator (ICD) and 1 patient (5%) with prior myectomy. At baseline, mean New York Heart Association (NYHA) functional class was 2.4±0.5. Mean left ventricular outflow tract (LVOT) peak gradient and septal thickness were 89±37 mmHg and 24.9±5.1 mm, respectively. All procedures were performed with myocardial contrast echocardiography guidance. During ASA, 2.2±0.7 ml of absolute alcohol was injected in 1.4±0.5 septal perforators. Final procedural LVOT peak gradient was 20±16mmHg. Procedural success (defined as immediate LVOT peak gradient reduction >50%) was achieved in 20 patients (95%). There were no major complications. One patient (5%) required a temporary pacemaker for second-degree atrioventricular block. Mean peak CK was 934±468 IU/L. At a mean follow-up of 3.0±2.0 years after the procedure (range 0.3-8.4), repeat ASA was performed in two patients (10%) and a new ICD was needed in 1 patient (5%), while there were no fatalities reported. Mean NYHA class was improved to 1.6±0.7.