François Lesaffre

Risk factors for infection of implantable cardiac devices: data from a registry of 2496 patients

AIMS The increased use of implantable cardiac devices has been accompanied by an increase in infection. However, risk factors for infection of implanted devices are poorly documented. We aimed to identify risk factors in patients with long-term follow-up after implantation of cardiac devices. METHODS AND RESULTS Patients with first implantation of a cardiac device in our centre between October 1996 and July 2007 were entered in a registry. Each confirmed infection of the implanted device was matched to two controls for age, sex, and implantation year. We recorded cardiovascular risk factors (hypertension, diabetes), previous history of heart disease, renal failure, antiplatelet or anticoagulant therapy, as well as pre- and post-procedural characteristics (antibiotic prophylaxis, hyperthermia, number of leads, associated interventions, and early complications). During the study period, 2496 patients underwent implantation of a cardiac device; 35 infections were diagnosed (1.2%). Among these, 75% occurred during the first year after implantation. Early non-infectious complication requiring surgical intervention was observed only in patients with infection (9 of 35, P < 0.001). Factors independently associated with infection were diabetes [odds ratio (OR) 3.5, 95% confidence interval (CI) [1.03, 12.97]], underlying heart disease (OR 3.12, 95% CI [1.13; 8.69]), and use of >1 lead (OR 4.07, 95% CI [1.23, 13.47]). These latter two risk factors were also independently associated with occurrence of infection within 1 year of implantation. CONCLUSION Our data show that the presence of diabetes and underlying heart disease are independent risk factors for infection after cardiac device implantation. As regards procedural characteristics, the use of several leads and early re-intervention are associated with a higher infection rate.

Quantitative Genomic and Antigenomic Enterovirus RNA Detection in Explanted Heart Tissue Samples from Patients with End-Stage Idiopathic Dilated Cardiomyopathy

ABSTRACT Standardized one-step real-time RT-PCR assay detected enterovirus RNA in cardiac biopsy samples from 4 of 20 patients suffering from idiopathic dilated cardiomyopathy (IDCM). The median viral load was 287 copies per microgram of total extracted nucleic acids, with positive- to negative-strand RNA ratios ranging from 2 to 20. These results demonstrate enterovirus persistence in the heart of IDCM patients, characterized by low viral loads and low positive- to negative-RNA ratios.

Enterovirus but not Parvovirus B19 is associated with idiopathic dilated cardiomyopathy and endomyocardial CD3, CD68, or HLA‐DR expression

We assessed Enterovirus (EV) &Parvovirus B19 (PVB19) genomes and CD3, CD68&HLA‐DR detection in dilated cardiomyopathies (DCM). EV&PVB19 genomes and CD3, CD68&HLA‐DR were detected by PCR and immunohistochemistry assays in 115 endomyocardial biopsies obtained in 13 idiopathic DCM (iDCM) and 10 explained DCM (eDCM) patients. Results were compared with those of 47 atrial surgical samples (47 surgery controls) and 22 autoptic cardiac samples (11 healthy heart controls) (2008–2014, Reims, France). EV was detected in 23.1% of iDCM patients but not in eDCM and controls (P = 0.003) (viral load 803 copies/μg). PVB19 was detected in 76.9%, 80.0%, 63.6% and 78.2% of iDCM, eDCM, healthy heart and surgery controls (P = 0.99) with a mean viral load of 413, 346, 1,428, and 71 copies/μg. CD3, CD68 or HLA‐DR were detected in 100 and 50% of EV and PVB19 “mono‐infected” iDCM patients. EV was exclusively detected in iDCM cases in association with CD3, CD68, or HLA‐DR indicating that EV could be an etiological cause in a subset of iDCM cases. By contrast the equal frequent detection of PVB19 in iDCM cases and controls without association with CD3, CD68, or HLA‐DR suggested that PVB19 could be a bystander in many DCM cases. J. Med. Virol. 89:55–63, 2017.

Enterovirus but not Parvovirus B19 is associated with idiopathic dilated cardiomyopathy and endomyocardial CD3, CD68 or HLA-DR expression. Revised version R1.

We assessed Enterovirus (EV) &Parvovirus B19 (PVB19) genomes and CD3, CD68&HLA‐DR detection in dilated cardiomyopathies (DCM). EV&PVB19 genomes and CD3, CD68&HLA‐DR were detected by PCR and immunohistochemistry assays in 115 endomyocardial biopsies obtained in 13 idiopathic DCM (iDCM) and 10 explained DCM (eDCM) patients. Results were compared with those of 47 atrial surgical samples (47 surgery controls) and 22 autoptic cardiac samples (11 healthy heart controls) (2008–2014, Reims, France). EV was detected in 23.1% of iDCM patients but not in eDCM and controls (P = 0.003) (viral load 803 copies/μg). PVB19 was detected in 76.9%, 80.0%, 63.6% and 78.2% of iDCM, eDCM, healthy heart and surgery controls (P = 0.99) with a mean viral load of 413, 346, 1,428, and 71 copies/μg. CD3, CD68 or HLA‐DR were detected in 100 and 50% of EV and PVB19 “mono‐infected” iDCM patients. EV was exclusively detected in iDCM cases in association with CD3, CD68, or HLA‐DR indicating that EV could be an etiological cause in a subset of iDCM cases. By contrast the equal frequent detection of PVB19 in iDCM cases and controls without association with CD3, CD68, or HLA‐DR suggested that PVB19 could be a bystander in many DCM cases. J. Med. Virol. 89:55–63, 2017.

Serum and Tissue Accumulation of Advanced Glycation End-Products Correlates with Vascular Changes.

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Echocardiography to predict adverse cardiac and vascular events in patients with severe chronic kidney disease (stage 4): A prospective study

BACKGROUND Cardiovascular disease is the primary cause of mortality and morbidity among patients with chronic kidney disease. AIMS To investigate whether echocardiography can predict the occurrence of major cardiovascular events in patients with severe chronic kidney disease. PATIENTS Patients with stable stage 4 chronic kidney disease (estimated glomerular filtration rate 15-29 mL/min/1.73 m(2)) and followed in the nephrology department were included. Clinical, biological, electrocardiographic and echocardiographic data were recorded. Endpoint was defined as fatal or non-fatal cardiovascular event (acute coronary syndrome, acute heart failure, stroke, sustained ventricular arrhythmias, arterial thrombotic events and death). RESULTS We included 71 patients (46 men); mean age 72±14 years. Mean glomerular filtration rate was 21.9±4.8 mL/min/1.73 m(2). Over a mean follow-up of 258±30 days, 18 (25%) patients reached endpoint (death in 7/18). Male sex, blood urea, atrial fibrillation, Sokolow index, left atrial size, pulmonary arterial pressure, indexed left ventricular mass and protodiastolic peak velocity of transmitral Doppler flow were significantly higher whereas left ventricular ejection fraction was significantly lower in these patients. By multivariable analysis, blood urea and left ventricular ejection fraction remained predictive of major cardiovascular event with odds ratios of 1.10 (95% confidence interval 1.02-1.18) and 0.93 (95% confidence interval 0.89-0.97), respectively. The negative predictive value was 95% when left ventricular ejection fraction was>50% with blood urea<15 mmol/L. CONCLUSION Patients with stage 4 chronic kidney disease are at high risk of major cardiovascular events and death. Echocardiographic evaluation is effective in identifying patients at highest risk of adverse cardiac events.

No serological evidence for Borrelia burgdorferi sensu lato infection in patients with dilated cardiomyopathy in Northern France

We read with interest a recent review article in the present journal in which evidence in favour of Borrelia burgdorferi as an aetiological agent of vasculitis and stroke was presented.[1] A more controversial issue seems to be the possible role of Borrelia burgdorferi sensu lato (BBSL) in the development of dilated cardiomyopathy (DCM).[2–5] The pathophysiological process leading to DCM is presumed to be due to the persistence of BBSL in myocardium of infected patients after an episode of myocarditis leading to the production of anti-endothelial or/and anti-heart antibodies and therefore to the development of an apparently ‘idiopathic’ DCM (iDCM).[4] The arguments for such process were: BBSL positive serology, BBSL detection in endomyocardial biopsies (EMBs) using microscopy or polymerase chain reaction (PCR) assays and improvement of patient’s cardiac condition after treatment by ceftriaxone.[6] However, at the opposite end of cardiac conduction abnormalities,[7] the response to such antibiotic treatment was not present in all iDCM patients suggesting an absence of active BBSL infection despite positive serological and/or molecular detection assays.[6] Moreover, systematic treatment of iDCM patients could not be considered in clinical practice because exposure to ceftriaxone may lead to acquiring extended-spectrum b-lactamase-producing gram-negative rods that are now one of the main health concerns worldwide. Taking into account all these elements, physicians in care of iDCM patients shall try to predict which patient may benefit from an antibiotic treatment by ceftriaxone only with the help of clinical context and biological investigations. This point remains difficult in clinical practice because previously reported cases [2–4] were based on direct bacteriological examination, culture or PCR assays on EMBs, whose indications are limited in clinical practice, according to the current American Heart Association (AHA) and European Society of Cardiology (ESC) recommendations.[8] Because serological screening remains the sole non-invasive test in this setting, we performed a BBSL serological screening of IgG and IgM using ELISA Enzygnost borreliosis Vlse (SiemensR ) in the serum or plasma of 15 patients suffering from iDCM and followed regularly in Reims University Hospital. All of these patients were living in North-eastern France where Lyme borreliosis is endemic.[9] EMBs had been prospectively performed in 10 out of the 15 study iDCM patients, according to AHA and ESC recommendations.[8] All sera with positive or borderline BBSL antibody results were tested by Western blot analysis (Borreliosis reference centre’s in-house immunoblot assay using Borrelia garinii IB6 antigens). Western blot analysis was interpreted as positive in case of reactivity to more than 4 BBSL antigens. EMBs were also routinely screened by PCR for the presence of common cardiotropic viruses (Enterovirus, Parvovirus B19, Human Herpes Virus) using Argene BiomerieuxR commercial kits, according to manufacturer’s instructions. Clinical data were extracted from medical records. The Hospital Ethics Committee approved the study, and informed consent had previously been obtained from each of the patients. Results are depicted in the Table 1. BBSL seroprevalence reported in our study’s population was zero [95% confidence interval: 0.07 to 0.19]; excluding the implication of BBSL in the development of DCM in any of our 15 study patients that were all living in Northern France. Therefore, we did not perform BBSL detection by PCR assays in available EMBs because

0334 : Implantable cardioverter defibrillator in primary prevention for chronic heart failure: incidence and predictors of appropriate therapy

Background Considering morbidity and financial impact on the health care system, it may be helpful to stratify patients who would most benefit from primary ICD treatment. The aim of this study was to assess the prevalence and identify the clinical predictors of appropriate ICD therapy in patients following implantation of an ICD in primary prevention for chronic heart failure. Methods A monocenter retrospective analysis was performed and all patients undergoing implantation of ICD in primary prevention were included. Device interrogations were performed and appropriate therapies, either ATP or shock, were noticed. Results Over the 317 primary prevention patients undergoing ICD implantation, 203 had ischemic cardiomyopathy (ICM) and 114 had nonischemic dilated cardiomyopathy (NIDCM). At the median follow-up time 760±599 days, 56 (17,7%) had received appropriate ICD therapies. Average Download : Download full-size image Figure: Predictors of appropriate ICD therapy LVEF was 26±6%. By univariate comparison, LVDD≥65mm (p=0,035) and lack of diuretic (p=0,024) were significant predictors for ICD therapy. ICM and NIDCM patients benefit equivalently from ICD implantation (p=0,941). By multivariate analysis, elderly patients ≥65y (HR 1,92, p=0,032), LVDD≥65mm (HR 2,01, p=0,022) and lack of diuretic (HR 0,31, p Conclusions ICD therapy occurred in 17,7% of primary prevention patients with both ICM and NIDCM. In multivariate analysis, age ≥65y, LVDD≥65mm and absence of diuretic were predictive factors for ICD therapy. Presence of CRT device was closed to be significant. There was no difference by considering heart failure etiology, ICM and NIDCM patients benefited from ICD equivalently.

0218: Comparison of transvenous versus surgical implantation of left ventricular lead for cardiac resynchronization therapy

Background Approximately 1% of the adult population have heart failure with reduced ejection fraction. Since the 1980s, therapeutic advances in this field have been significant, particularly through the development of cardiac resynchronization therapy (CRT). However, transvenous implantation of the left ventricular (LV) lead is unsuccessful in 5 - 15% of patients. For this group, surgical placement of LV lead is an alternative. Objective Compare the effects of transvenous versus surgical implantation of the LV lead in CRT. Methods We included 100 consecutive patients who had received CRT in our centre between January 2008 and July 2012 in a retrospective observational study. Twelve patients who had failed transvenous implantation of LV lead had a surgical placement. Results Population characteristics were a mean age of 66±11 years, 16% female, New York Heart Association class 2.9±0.5, 45% ischemic cardiomyopathy, left ventricular ejection fraction (LVEF) 24±7%, QRS width 165±23ms. There were no major difference in preoperative variables between two groups except sex category (12.5% female in transvenous group versus 42% in surgical group, p=0.022). During a mean follow-up of 508±429 days, the improvements seen in all variables showed no difference between the groups. At six months, 77% of patients had improved at least one class of their dyspnea stage, LVEF improved significantly (24±7% versus 36±10% at six months). Conclusions Surgical placement of LV lead offers similar benefits as compared with transvenous implantation.

196: Impact of frailty and dependence on anticoagulant treatment prescription in older persons with atrial fibrillation

Introduction Studies have documented the underuse of oral anticoagulant therapy (OAC) as stroke prophylaxis in older persons with history of atrial fibrillation (AF). Failure to prescribe OAC is often due to the perception by physicians of bleeding because of specific older people clinical factors. We performed a prospective observational study in the University Hospital of Reims, whose aim was to evaluate the management of thromboembolic risk in older patients in everyday-life hospital practice and impact of frailty and dependence objective parameters. Method 150 AF patients over 75 years were consecutively included over a period of four months. Clinical and biological data, risk scores for bleeding (HASBLED) and thrombo-embolic events (CHADS and CHADSVASc) were computed. Several scores and parameters of assessment of autonomy and risk of falling were independently recorded: MMS (Mini-Mental Status), ADL (Activities of Daily Living) and IADL (Instrumental ADL). Results Mean age was 83±13 years (75 men). At discharge, 52.2% of patients were under OAC. Mean CHADS, CHADSVASc and HASBLED score were respectively 2,6±0,1, 4,6±0,1 and 2,3±0,1; all patients had a CHA DS VASc score ≥2 and 86% a CHADS ≥2. The HASBLED score was associated with non-prescription of anticoagulation (p=0.001), while none of the thrombo-embolic scores was significantly associated with prescription. Specific studied parameters are in table. Anticoagulation N=74 No anticoagulation N=68 p Age (years) 81.8±0.5 84.6±0.6 0.001 Creatinine (μmol/l) 106±7.3 127.3±6.3 0.03 Dependency (%) 27 54 0.001 Dementia (%) 4,1 14,7 0.04 High risk of falling (%) 0 20 0,001 MMS score 21.4±1.2 20.1±1.1 NS ADL score 5.1±0.3 3.8±0.4 0.001 IADL score 2±0.2 2.4±0.4 NS Conclusion In our study of everyday practice, there is an underuse of anticoagulation in the elderly compared to guidelines, mainly because the perception of the hemorrhagic risk prevails over the thrombo-embolic risk. Specific geriatric parameters could help to choose the appropriate therapy.