Guillaume Clerfond

A single pathophysiological pathway in Takotsubo cardiomyopathy: Catecholaminergic stress

BACKGROUND Takotsubo cardiomyopathy (TTC) continues to be under-diagnosed, due to its varying presentation, with potentially serious consequences if treatment is delayed. AIMS To demonstrate the consistent involvement of catecholaminergic stress in TTC, regardless of the trigger. METHODS Between 01 July 2009 and 31 August 2013, patients managed in our centre for thoracic pain syndrome, with or without troponin release, were followed up prospectively. TTC was diagnosed from the apical ballooning seen on left ventricular imaging (angiography or transthoracic echocardiography) in the absence of a significant coronary artery lesion. Triggers (emotional trauma, surgical stress and β2-mimetic intoxication) were recorded; catecholamine-secreting tumours were screened for with a urinary methoxylate-derivative assay. RESULTS TTC was diagnosed in 40 out of 2754 (1.5%) patients with thoracic pain syndrome, with or without troponin release. Triggers were emotional trauma (n=29, 72.5%), surgical stress (n=5, 12.5%), adrenergic intoxication (n=3, 7.5%) and catecholaminergic tumour (n=3, 7.5%). Mean left ventricular ejection fraction at admission was 38.0 ± 15.7%. Eight (20%) patients initially showed cardiogenic shock. In-hospital mortality was 7.5%, with no deaths from cardiogenic causes. Thirty-five (94.6%) of the survivors had recovered a normal left ventricular ejection fraction (> 55%) by discharge. CONCLUSION Whatever the trigger, the common denominator in TTC is catecholaminergic stress. Classically suggested after emotional trauma, TTC may also be induced by surgical stress or endogenous or iatrogenic β2-mimetic intoxication. The various contexts all have a similarly excellent cardiovascular prognosis if treated early.

Acute and Chronic Pheochromocytoma-Induced Cardiomyopathies: Different Prognoses?: A Systematic Analytical Review.

AbstractPheochromocytoma and paraganglioma (PPG) are rare and late-diagnosed catecholamine secreting tumors, which may be associated with unrecognized and/or severe cardiomyopathies.We performed a computer-assisted systematic search of the electronic Medline databases using the MESH terms “myocarditis,” “myocardial infarction,” “Takotsubo,” “stress cardiomyopathy,” “cardiogenic shock”, or “dilated cardiomyopathy,” and “pheochromocytoma” or “paraganglioma” from 1961 to August 2012. All detailed case reports of cardiomyopathy due to a PPG, without coronary stenosis, and revealed by acute symptoms were included and analyzed.A total of 145 cases reports were collected (49 Takotsubo Cardiomyopathies [TTC] and 96 other Catecholamine Cardiomyopathies [CC]). At initial presentation, prevalence of high blood pressure (87.7%), chest pain (49.0%), headaches (47.6%), palpitations (46.9%), sweating (39.3%), and shock (51.0%) were comparable between CC and TTC. Acute pulmonary edema (58.3% vs 38.8%, P = 0.03) was more frequent in CC. There was no difference in proportion of patients with severe left ventricular systolic dysfunction (LV Ejection Fraction [LVEF] < 30%) at initial presentation between both groups (P = 0.15). LVEF recovery before (64.9% vs 40.8%, P = 0.005) and after surgical resection (97.7% vs73.3%, P = 0.001) was higher in the TTC group. Death occurred in 11 cases (7.6%). In multivariate analysis, only TTC was associated with a better LV recovery (0.15 [0.03–0.67], P = 0.03).Pheochromocytoma and paraganglioma can lead to different cardiomyopathies with the same brutal and life-threatening initial clinical presentation but with a different recovery rate. Diagnosis of unexplained dilated cardiomyopathy or TTC should lead clinicians to a specific search for PPG.

Comparison of Outcomes After One-Versus-Two Transcatheter Aortic Valve Implantation During a Same Procedure (from the FRANCE2 Registry)

Analysis of the causes, outcomes, and mortality of patients with severe symptomatic aortic stenosis requiring the implantation of 2 valves during transcatheter aortic valve implantation was conducted from the French Aortic National CoreValve and Edwards 2 (FRANCE2) registry. Pre- and postprocedural data from 3,919 patients from January 2010 to December 2011 (CoreValve or Edwards) were collated and analyzed. Characteristics of patients requiring immediate second valve procedures were compared with those of the other patients. The 72 patients (1.8%) who underwent implantation of a second valve were studied. Indications were device malpositioning (72%) and embolization (28%). Clinical and echocardiographic characteristics of patients receiving 2 valves were comparable with those of the other patients. The 2-year survival rate was 51.7% for patients with 2 valves as opposed to 62.3% for those with 1 valve (p<0.001). The need for a second valve was an independent predictor of all-cause (hazard ratio 2.32, 95% confidence interval 1.50 to 3.60, p<0.001) and cardiovascular (hazard ratio 2.64, 95% confidence interval 1.35 to 5.15, p<0.001) mortality at 2 years. During follow-up, clinical and echocardiographic data remained similar between the 2 groups. In conclusion, in the FRANCE2 study, the main causes for second valve implantation during the same procedure were malpositioning and embolization. Although the procedure was feasible, it was accompanied by excess mortality. Valve hemodynamic status was preserved during the course of follow-up.

0369: Heart failure octogenarians are poorly managed and treated: a cohort study in the French national healthcare insurance database

Aims Part of over 80-year-old heart failure (HF) patients is increasing. These patients are poorly studied. The present study undertook a ‘real-life’ analysis of various aspects of the prognosis of over 80-year-old HF patients in France. Methods and results Analysis was based on the EGB (“Echantillon Generaliste des Beneficiaires”) database, a continuously updated representative sample of the population covered by the French national health insurance system. A cohort of adult patients with a first admission for HF was created between 2009 and 2011 and followed until June 2013 for survival analysis. Over 80-year-old patients represented 53% (n=969/1825) of hospitalizations for HF. In octogenarians, in-hospital mortality was 10.9% [9.6-12.2] and mean 12 –, and 24-months survival 62.3% (range, 59.1-65.4) and 48.2% (44.8-51.5). Only prescription levels for beta-blockers (BB) (p=0.02) increased during the follow-up period. Only 5% of patients received at discharge an optimal treatment [association of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) +BB+mineralocorticoid receptor antagonists (MRA)]. During this period there was no increase of ACEi and ACEi/ ARB+BB+MRA prescription at discharge (p=0.48 and p=0.87, respectively). On multivariate analysis, atrial fibrillation [HR: 0.77(0.65–0.91), p=0.003], female gender [0.80(0.67–0.95), p=0.01] and the associations ACEi/ ARB+BB+MRA [0.49(0.29–0.85), p=0.01] and ACEi/ARB+BB [0.54(0.43– 0.68), p Conclusion Octogenarians HF patients are poorly managed and treated according to international guidelines despite the clinical benefit of such drugs confirmed in this un-selected cohort with several comorbidities.

Bioimpedance analysis is safe in patients with implanted cardiac electronic devices

BACKGROUND & AIMS There is an increase in the number of patients worldwide with cardiac implantable electronic devices (CIEDs). Current medical practice guidelines warn against performing bioimpedance analysis (BIA) in this group of patients in order to avoid any electromagnetic interference. These recommendations restrict using the BIA in patients undergoing heart failure or with nutrition disorders in whom BIA could be of major interest in detecting peripheral congestion and to help guide treatment. The present study was conducted to evaluate whether BIA caused electromagnetic interference in patients having CIEDs. METHODS Patient enrollment was conducted during routine face-to-face consultations for scheduled CIEDs interrogations. Device battery voltage, lead impedance, pacing thresholds and device electrograms were recorded before and after each BIA measurement to detect any electromagnetic interference or oversensing. RESULTS A total of 200 patients were enrolled. During BIA, no significant changes in battery voltage, lead impedance or pacing thresholds were detected, nor were there any inappropriate over- or undersensing observed in intracardiac electrograms. Furthermore, 6- and 12-month follow-up did not reveal any changes in CIEDs. CONCLUSIONS This study shows no interference in patients equipped with CIEDs and suggests that BIA can be securely performed in these patients. Trial registered under the identifier NCT03045822.

Innovative invasive management without stent implantation guided by optical coherence tomography in acute coronary syndrome

BACKGROUND A two-step strategy of invasive management without stenting, guided by optical coherence tomography (OCT), in selected patients with acute coronary syndrome (ACS), might avoid systematic stent implantation and allow medical therapy alone. AIMS To assess the feasibility and safety of such a procedure, and to define coronary imaging characteristics in a specific population. METHODS This single-centre proof-of-concept study included all patients with ACS who benefited from a two-step revascularization procedure with optimal reperfusion during primary percutaneous coronary intervention followed by delayed angiography and OCT. OCT imaging determined medical therapy treatment alone without stenting in case of absence of vulnerable plaque rupture and <70% stenosis. Follow-up consisted of screening for major adverse cardiac events (MACE) at 12months. RESULTS Forty-six patients were included, mainly men (86.9%) and smokers (65.2%), with a mean age of 47.1years. Most cases (80.4%) were large thrombus burden lesions. Delayed angiography and OCT were performed in a median period of 6 [3-10] days. No adverse events occurred between the initial and second angiograms. Plaque rupture was detected in 39.1% of patients, plaque erosion in 54.3% and calcified nodule in 6.5%. Twenty-three patients benefited from systematic delayed OCT over a median period of 171days, showing an increase in minimal lumen area. At 12months, two patients (4.3%) presented MACE and were stented. No sudden death or myocardial infarction recurrence occurred. CONCLUSIONS Analysing ACS mechanisms by OCT might facilitate treatment decisions in patients with ST-segment elevation myocardial infarction managed by a two-step procedure. Conservative treatment with antithrombotic therapy without stenting seems to be a reliable option in a selected population.

Effect of Optimization of Medical Treatment on Long-Term Survival of Patients With Heart Failure After Implantable Cardioverter Defibrillator and Cardiac Resynchronization Device Implantation (from the French National EGB Database)

Prognosis of heart failure with reduced ejection fraction (HFrEF) is improved by drug optimization according to guidelines; however, little is known regarding such optimization in HFrEF patients with an implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT). This study aimed to describe implementation of this optimized strategy and its impact in patients implanted with an ICD/CRT. Using a 1/97th representative sample of the French national health-care insurance system claims database, a retrospective cohort study was conducted including HFrEF patients implanted with ICD or CRT between January 2009 and December 2014. HFrEF treatments were analyzed before and after ICD/CRT implantation. Heart failure (HF) hospitalization and survival were examined at 1, 3, and 5 years: 378 patients (135 CRT, 243 ICD) with a mean age of 68 ± 13 years were included. Mean follow-up was 23 months [11-42]. At baseline, 36% of patients had no or only 1 HFrEF drug among β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and mineralocorticoid receptor antagonists, whereas 26% of patients received an optimal treatment (all 3 classes). At 3 months after ICD/CRT implantation, the prescription rate of HFrEF drugs was higher than baseline but returned to preimplantation levels at the end of follow-up. HF hospitalization rate was higher in the nonoptimized patient group (28% vs 14%, p = 0.001). Optimal HFrEF treatment was associated with better survival (hazard ratio = 0.59 [0.4-0.86], p = 0.006). In conclusion, HFrEF drugs are underprescribed before and after ICD/CRT implantation despite the demonstration that HFrEF drug optimization also reduces death and HF hospitalization in this population.

Optimized management of heart failure patients aged 80 years or more improves outcomes versus usual care: The HF80 randomized trial☆

BACKGROUND The prevalence and incidence of heart failure (HF) in elderly patients are increasing worldwide. Management of HF with reduced ejection fraction (HF-REF) in patients aged 80 years or more follows international guidelines, despite the lack of a dedicated study in this frail population. AIMS To determine whether optimized management of HF-REF in patients aged 80 years or more can improve quality of life at 6 months. METHODS Patients aged 80 years or more hospitalized for acute HF-REF were randomized prospectively into an optimized group or a control group (usual care). All patients benefitted from the same in-hospital management. Optimized group patients were also managed at 3, 6 and 9 weeks, and 3, 6, 9 and 12 months after initial hospitalization, to optimize HF-REF treatment. The primary endpoint was quality of life at 6 months. RESULTS The trial was stopped prematurely, according to prespecified rules and an independent data monitoring board, after 34 patients were included (n=17 in each group). There was no difference in quality of life at baseline and at 6 months between the two groups (P=0.14 and 0.64, respectively), although a significant improvement was observed between baseline and 6 months in the optimized group compared with the control group: -20.2±25.2 (P=0.01) versus -9.9±19.0 (P=0.19). Mortality at 12 months was lower in the optimized group (17.7% vs 47.1%; P=0.03). There was no increase in acute renal failure, hyperkalaemia or falls in the optimized group (P=0.49, 1 and 1, respectively). CONCLUSIONS Optimizing the management of HF-REF in patients aged 80 years or more, according to the modalities of the HF80 study, seems to be both effective and safe.

0308: Longitudinal 2D strain predicts severe coronary artery disease in patients with NSTEMI, normal left ventricular ejection fraction and no wall motion abnormality

Background In the era of high-sensitivity troponin, numerous patients are characterized with NSTEMI. Noninvasive tools are needed for early risk stratification. Longitudinal strain provided by speckle tracking echocardiography (2D-STE) has been proved to be very sensitive for diagnosing sub-clinical myocardial injuries, especially in the setting of ischemia. The aim of this study was to study speckle tracking longitudinal strain for early risk stratification in NSTEMI with no sign of myocardial dysfunction (left ventricular ejection fraction (LVEF) >50% and no abnormality of regional wall motion). Methods and results 40 patients were prospectively examined by echocardiography immediately prior to coronary angiography after a first hospitalisation for NSTEMI. Global longitudinal strain (GLS) was provided semi automatically and we calculated territorial longitudinal strains (TLS) on the basis of the perfusion areas of the 3 major coronary arteries, by averaging all segmental peaks systolic strain values within each territory. The subjects were classified into three groups depending on the extent of CAD: no significant CAD, one-vessel and two-vessel CAD (excluding left main [LM] or proximal left anterior descending [LAD] arteries), three-vessel CAD or LM and proximal LAD arteries involvement (qualified as severe CAD). A significant worsening of GLS depending on the extent of CAD was found (-21±1.6% [no significant CAD] vs. -19.9±1.8% [1 or 2 -vessel disease] vs. -7.2±2.2% [severe CAD] p= 0.002). Multivariate analyses have confirmed that only GLS (OR: 5.62; 95%CI: 1.40 to 22.60 p=0.015) prognosticates severe CAD. Receiver operating characteristic (ROC) curves analyses of GLS showed a cut-off value of - 18%, to identify patients with severe CAD. Conclusion This study confirms that in NSTEMI with no sign of myocardial dysfunction, GLS enables rapid risk stratification and predicts severe CAD with excellent accuracy.