Frédéric Franceschi

Long-term outcomes following infection of cardiac implantable electronic devices: a prospective matched cohort study

Objective To assess long-term outcomes and predictors of mortality in patients treated according to current recommendations for cardiac implantable electronic device (CIED) infection. Design Two-group matched cohort study. Setting Tertiary-care institution. Patients Consecutive patients admitted for CIED infection between 2004 and 2008 were prospectively enrolled. Study subjects were matched to a cohort of uninfected CIED patients by age, sex and type of device. Interventions In all infected patients, the therapeutic approach consisted of complete hardware removal whenever possible, antimicrobial therapy, and implantation of a new device, if indicated. Patients were systematically followed, with standardised outcomes assessment. Main outcome measures All-cause mortality and predictors of long-term mortality. Results 197 patients were included and matched 1:1 to controls. Pocket infections were present in 41.1% and definite or suspected infective endocarditis in 58.9%. Total or subtotal hardware removal was achieved in 98.5% of cases. Median follow up was 25 months (12–70). Mortality rates in the study group and controls were 14.3% vs 11.0% (NS) at 1 year and 35.4% vs 27.0% (p=NS) at 5 years. Independent predictors of long-term mortality were older age (HR=1.09, p<0.001), cardiac resynchronisation therapy (HR=3.70, p=0.001), thrombocytopenia (HR=5.10, p=0.003) and renal insufficiency (HR=2.66, p=0.006). In patients with reimplanted devices, epicardial right ventricular pacemakers were associated with higher mortality (HR=2.85, p=0.034). Conclusion In patients with CIED infection managed by recommended therapy, long-term mortality rates are similar to comparable controls. Independent predictors include patient and disease-related factors, in addition to implantation of right ventricular epicardial pacemakers.

Validation of an echocardiographic multiparametric strategy to increase responders patients after cardiac resynchronization: a multicentre study

AIMS We sought to develop and validate a multiparametric algorithm by applying previously validated criteria to predict cardiac resynchronization therapy (CRT) response in a multicentre study. Thirty per cent of patients treated by CRT fail to respond to the treatment. Although dyssynchrony by echocardiography has been used to improve the selection of patients, the complexity of myocardial contraction has generated a moderate improvement using any of several individual parameters. METHODS AND RESULTS Two hundred end-stage heart failure patients [NYHA 3-4 and left ventricular ejection fraction (LVEF)<35%] with QRS>120 ms were included. Echocardiography analysis focused on the following parameters: atrioventricular dyssynchrony, interventricular dyssynchrony, and intraventricular dyssynchrony that integrated radial (PSAX M-mode) and longitudinal [tissue Doppler imaging (TDI)] evaluations for spatial (wall to wall) and temporal (wall end-systole to mitral valve opening) dyssynchrony diagnosis. Following CRT implantation, patients were monitored for 6 months with functional and echo evaluations defining responders by a 15% reduction in end-systolic volume. Mean QRS duration and LVEF were 152 +/- 17 ms and 25 +/- 8%. There was a CRT response in 57% of patients, independent of QRS width. Mean prevalence of positive criteria was 34 +/- 8%. Feasibility and variability averages were 81 +/- 20% and 9 +/- 4%. In a single parametric approach, ranges of sensitivities and specificities were 18-65% and 45-84% with a mean of 41% and 66%. A multiparametric approach by focusing on criteria combination decreased the mean rate of false-positive results to 14 +/- 12%, 5 +/- 4%, 2 +/- 2%, and 1 +/- 2% from one to four parameters, respectively. More than three parameters were associated with a specificity above 90% and a positive predictive value above 65%. Reproducibility of this global strategy was 91%. CONCLUSION A multiparametric echocardiographic strategy based on the association of conventional criteria is a better indicator of CRT response than the existing single parametric approaches.

Incidence, Risk Factors, and Outcome of Traumatic Tricuspid Regurgitation After Percutaneous Ventricular Lead Removal

OBJECTIVES This study sought to evaluate the incidence, risk factors, and outcome of traumatic tricuspid regurgitation (TTR) induced by percutaneous removal of chronically implanted transvenous leads. BACKGROUND Although lead removal using modern tools has been shown to be highly effective and safe, TTR has not been systematically evaluated. METHODS All patients undergoing ventricular lead removal at our center were studied. Lead removal was performed by simple traction, laser sheath, and/or lasso technique. Presence of a new TTR after removal was assessed by transthoracic echocardiography. Pre-defined clinical and technical parameters were studied for their association with TTR. Patients were followed up by outpatient visits. RESULTS We removed 237 ventricular leads in 208 patients. Median time from lead implantation was 46.4 months (range 0.7 to 260.5 months). A TTR occurred in 19 patients (9.1%), severe in 14. Three independent risk factors of TTR were found: use of laser sheath (p = 0.004), use of both laser sheath and lasso (p = 0.02), and female sex (p = 0.02). After a follow-up of 4,130 person-months (median 17.9 months), 5 TTR patients were medically treated for new right-sided heart failure symptoms, 2 had undergone surgical repair of the tricuspid valve, and 6 had died (2 from heart failure and 4 from noncardiac causes). Right-sided heart failure occurred only in patients with severe TTR. CONCLUSIONS This study found that TTR is not uncommon after percutaneous lead removal. It is strongly associated with the use of additional tools beyond simple traction and also with female sex. In the long term, right-sided heart failure is frequent in patients with severe TTR.

Novel Electromyographic Monitoring Technique for Prevention of Right Phrenic Nerve Palsy During Cryoballoon Ablation

Background—Right phrenic nerve palsy (PNP) is the most frequent complication of cryoballoon ablation. Diaphragmatic electromyography can predict PNP with a comfortable safety margin. Our goal was to evaluate the feasibility, efficacy, and safety of electromyography-guided PN monitoring using a novel hepatic vein approach for prevention of PNP. Methods and Results—This study includes 57 patients (47 males) indicated for cryoballoon ablation for treatment of atrial fibrillation. During right superior pulmonary vein ablation, the PN was paced at 60 beats per minute and diaphragmatic compound motor action potential (CMAP) amplitude was recorded via a quadripolar catheter positioned in a subdiaphragmatic hepatic vein. If a 30% drop in CMAP amplitude was observed, ablation was discontinued with forced deflation. Reliable recording of CMAP before ablation was feasible in 50 of 57 patients (88%). In 7 patients (12%), stable PN pacing could not be achieved. In 44 of 50 patients, CMAP amplitude remained constant during cryoapplication. The mean value of CMAP amplitude was 639.7±240.5 µV; mean variation was 13±4.3%. In 6 of 50 patients (12%) including 5 treated with a 23-mm cryoballoon and 1 with a 28-mm cryoballoon, the 30% reduction cutoff was reached and cryoablation was discontinued. Recovery of CMAP amplitude after discontinuing cryoablation took <60 seconds in all cases. No PNP or complication related to PN monitoring occurred. Conclusions—Recording of diaphragmatic CMAP using a catheter positioned in a subdiaphragmatic hepatic vein seems feasible during cryoballoon ablation. Electromyography-guided PN monitoring seems safe and potentially helpful for prevention of PNP.

Adenosine plasma level and A2A adenosine receptor expression: correlation with laboratory tests in patients with neurally mediated syncope

Objectives The purpose of this study was to investigate the hypothesis that responses to the ATP test and head-up tilt test (HUT) may be correlated with different purinergic profiles. Design and setting The ATP and HUT identify distinct subsets of patients with neurally mediated syncope (NMS). Adenosine and its A2A receptors (A2AR) may be implicated in the pathophysiology of NMS in patients with positive HUT. Nothing is known about the purinergic profile of patients with positive ATP. Patients and measures This prospective study includes a consecutive series of patients with suspected NMS. All patients underwent both HUT and ATP. Before testing, samples were collected for measurement of baseline adenosine plasma level (APL) and expression. Results A total of 46 patients (25 men and 21 women) with a mean age of 57±18 years were enrolled. The HUT test was positive in 27 patients and the ATP test in 20. Both tests were positive in 9 and negative in 8. High APL was associated with high probability of positive HUT while low APL was associated with high probability of positive ATP. Expression of A2AR was lower in patients with positive ATP than in those with positive HUT. Conclusion These findings indicate that patients with NMS present different purinergic profiles and that responses to HUT and ATP are correlated with these profiles.

Extraction of transvenous leads in the operating room versus electrophysiology laboratory: A comparative study

BACKGROUND Although risks and life-threatening complications associated with lead extraction are well characterized, practice patterns vary regarding whether procedures are performed in an operating room (OR) or electrophysiology (EP) laboratory with cardiothoracic surgical backup. OBJECTIVE Our objective was to compare procedural outcomes and complications associated with lead extraction in the OR vs. EP laboratory. METHODS Prospectively acquired data were pooled from 2 referral centers. Lead extraction procedures were performed between 2000 and 2010, encompassing a transition phase from the OR to EP laboratory. Analyses were conducted using generalized estimating equations. RESULTS A total of 1,364 leads (533 OR; 831 EP laboratory) were targeted in 684 consecutive procedures, 41.2% of which were in the OR. Laser sheaths and snares were used for 699 (51.2%) and 101 (7.4%) leads, respectively. Overall, 775 (93.1%) vs. 487 (91.4%) leads were completely extracted in the EP laboratory vs. OR [odds ratio 1.3, 95% confidence interval 0.9 to 2.1]. Complications occurred in 2.24% vs. 2.84%, respectively (P = .431). Two patients died because of superior vena caval lacerations (0.29%), 1 in each group. Rapid surgical intervention was helpful in 6 (0.9%) patients [4 OR (2 subclavian vein lacerations, 1 tricuspid valve laceration, 1 tamponade); 2 EP laboratory (tamponades)], with subsequently favorable outcomes. The only independent predictor of complications was older lead age [odds ratio 1.11 per year, 95% confidence interval 1.02 to 1.20]. CONCLUSION Lead extraction in the EP laboratory with surgical backup is associated with a similarly low rate of complications and mortality as procedures performed in the OR.

Electromyographic monitoring for prevention of phrenic nerve palsy in second-generation cryoballoon procedures.

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 <60 s. In 9 of 18 cases, a second cryoapplication in the same pulmonary vein was safely performed. We observed no PNP or complication related to electromyography-guided PN monitoring. 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.

Peripheral plasma adenosine release in patients with chronic heart failure

Objective: Chronic heart failure (CHF) is accompanied by increased adenosine plasma levels (APLs). It is unknown whether adenosine release occurs at the peripheral level or whether the myocardium itself is the source of adenosine release. To answer this question, we evaluated APLs in the coronary sinus of CHF patients during a resynchronisation procedure and compared the values with those at the peripheral level. We also investigated a possible correlation between APLs and ischaemia-modified albumin (IMA) levels, a useful marker of tissue ischaemia. Methods: 19 men and seven women were prospectively included. Blood samples for APLs were collected simultaneously from a brachial vein (peripheral) and from the coronary sinus. Blood samples for brain natriutretic peptide (BNP) and IMA were collected from a brachial vein. Results: APLs from the brachial vein were higher than those from the coronary sinus (1.69 vs 0.75 μM p<0.01). IMA levels were correlated with APLs from the brachial vein (r = 0.59, p<0.01). BNP concentrations were correlated with APLs from the brachial vein (r = 0.73, p<0.001) but not with APLs from the coronary sinus (r = 0.38, p>0.05). BNP concentrations and IMA levels were correlated (r = 0.71, p<0.001). Conclusions: In CHF patients, adenosine release occurs at a peripheral level and not at the myocardium level.

Adenosine and Clinical Forms of Neurally-Mediated Syncope

Central or peripheral baroreceptor reflex abnormalities, alterations in neurohumoral mechanisms, or both, are thought to play a role in causing neurally-mediated syncope. Because adenosine and its receptors are involved in some forms of syncope [(1–3)][1], we evaluated the purinergic profile of 4

A2A adenosine receptor function in patients with vasovagal syncope

AIMS Adenosine is a possible mediator in vasovagal syncope (VVS) via the activation of its receptors. High expression of adenosine A2A receptors (A2AR) has been reported in VVS. The function of these over-expressed receptors in this population has never been evaluated. METHODS AND RESULTS We used Adonis, a specific-made antibody with A2AR agonist properties, to evaluate binding parameters (i.e. dissociation constant KD) and cAMP production (i.e. EC50) by peripheral blood mononuclear cells of 16 VVS patients. Eight healthy volunteers served as controls. A2AR expression was higher in patients than controls; mean: 11.5 ± 1.2 vs. 7.7 ± 0.8 AU, P = 0.04. Also, KD values were higher in patients than controls: 2.1 ± 0.02 × 10(-7) vs. 5 ± 1 × 10(-8) M, P < 0.01 In controls, KD values were lower than EC50 (5 ± 1.7 × 10(-8) vs. 2.8 ± 0.4 10(-7) M, P < 0.01), but in patients, KD values did not differ from EC50: 2. ± 0.2 × 10(-7) vs. 2.5 ± 0.4 × 10(-7) M, P > 0.05. However, four patients had lower EC50 (3.5 ± 0.3 × 10(-8) M) than KD (2.9 ± 1.2 × 10(-7) M; KD/EC50 = 9.6), suggesting the presence of spare receptors. CONCLUSION The function of A2AR of patients with VVS was preserved since their stimulation by Adonis led to cAMP production with an EC50 comparable with those in controls. However, their affinity was lower than those of controls. Our results suggest that A2AR are implicated in the physiopathology of VVS.