Hervé Douard

Endocardial Biventricular Pacing

Simultaneous righ t and left ventricular pacing was performed in a 73‐year‐old man with coronary artery disease end‐stage congestive heart failure and a DDD pacemaker implanted for sick sinus syndrome. An endocardial LV lead was introduced transseptally after unsuccessful attempts to enter the coronary sinus. This new approach for multisite pacing offers an alternative to epicardial LV from the coronary sinus or by thoracotomy.

Automated function imaging: a new operator-independent strain method for assessing left ventricular function.

BACKGROUND Speckle tracking is a new technique based on pure 2D grayscale ultrasound acquisition allowing calculation of segmental strains. To facilitate clinical application, speckle tracking has been integrated into the most recent echocardiographic systems for quick, automated evaluation of left ventricular function (Automated Function Imaging, AFI). OBJECTIVE To evaluate the feasibility, calculation time, accuracy and reproducibility of global longitudinal strain (GLS) from AFI in determining LV function in comparison to reference echocardiographic and angiographic methods-whatever the operators experience. METHODS Echocardiography was performed in 65 patients scheduled for cardiac catheterization using a Vivid 7 system. They were divided into 3 groups according to EF (>55%, 35< or =EF< or =55%,<35%). Image quality, global LV function parameters (ejection fraction, aortic flow, dp/dt) and segmental contraction were analyzed by one experienced operator and one beginner. GLS was obtained from apical 2, 3 and 4 chamber views. GLS was compared to both echocardiographic and angiographic EF, as well as to other echocardiographic parameters. RESULTS GLS was obtained successfully in 97% of patients. Mean calculation time including correction of endocardial detection was less than 60 seconds. GLS was significantly different between the 3 groups, respectively -18.1+/-2.5%, -11.5+/-2.1% and -6.0+/-1.2% (p<0.01). Strong correlations were observed between GLS and LV function (r from 0.68 to 0.87) with a high level of reproducibility. No difference was observed between experienced and inexperienced operators. CONCLUSION AFI is clinically applicable and an effective means of assessing LV function due to its short acquisition time, feasibility and accuracy, whatever the experience of the operator.

Stopping or continuing clopidogrel 12 months after drug-eluting stent placement: the OPTIDUAL randomized trial.

AIM This open-label, randomized, and multicentre trial tested the hypothesis that, on a background of aspirin, continuing clopidogrel would be superior to stopping clopidogrel at 12 months following drug-eluting stent (DES) implantation. METHODS AND RESULTS Patients (N = 1799) who had undergone placement of ≥1 DES for stable coronary artery disease or acute coronary syndrome were included in 58 French sites (January 2009-January 2013). Patients (N = 1385) free of major cardiovascular/cerebrovascular events or major bleeding and on aspirin and clopidogrel 12 months after stenting were eligible for randomization (1:1) between continuing clopidogrel 75 mg daily (extended-dual antiplatelet therapy, DAPT, group) or discontinuing clopidogrel (aspirin group). The primary outcome was net adverse clinical events defined as the composite of death, myocardial infarction, stroke, or major bleeding. Follow-up was planned from a minimum of 6 to a maximum of 36 months after randomization. Owing to slow recruitment, the study was stopped after enrolment of 1385 of a planned 1966 patients. Median follow-up after stenting was 33.4 months. The primary outcome occurred in 40 patients (5.8%) in the extended-DAPT group and 52 in the aspirin group (7.5%; hazard ratio 0.75, 95% confidence interval 0.50-1.28; P = 0.17). Rates of death were 2.3% in the extended-DAPT group and 3.5% in the aspirin group (HR 0.65, 95% CI 0.34-1.22; P = 0.18). Rates of major bleeding were identical (2.0%, P = 0.95). CONCLUSIONS Extended DAPT did not achieve superiority in reducing net adverse clinical events compared to 12 months of DAPT after DES placement. The power of the OPTIDUAL trial was however low and reduced by premature termination of enrolment. CLINICALTRIALSGOV NUMBER NCT00822536.

French Society of Cardiology guidelines for cardiac rehabilitation in adults

text isan extract from thereference ‘‘Good Practice for Cardiac Rehabilitation inAdults 2011’’, which available onwebsite of GERS (Groupe Exercice Readaptation Sport of the French Society of Cardiology [Societe franc¸aise de cardiologie];http://www.sfcardio.fr/groupes/groupes/exercice-readaptation-sport) and contains the complete bibliography, replacing the FrenchSociety of Cardiology text of 2002, version 2, establishing recommendations for cardiac rehabilitation in adults.

Effect of catheter ablation for isolated paroxysmal atrial fibrillation on longitudinal and circumferential left ventricular systolic function.

Isolated paroxysmal atrial fibrillation (AF) is commonly associated with left ventricular (LV) diastolic dysfunction but normal radial systolic contraction. We aim to investigate LV systolic function more precisely using 2-dimensional strain technique in patients with isolated paroxysmal AF and to evaluate evolution of longitudinal, circumferential, and radial (or transverse) strain components after catheter ablation of AF. Thirty patients with isolated paroxysmal AF were investigated by echocardiographic studies before and at 1-day, 1-month, 6-month, and 12-month intervals after radiofrequency ablation. Left heart dimensions and LV systolic and diastolic functions were evaluated at each time interval. LV systolic function was quantified by LV ejection fraction and by 2-dimensional strain evaluation, giving regional and global longitudinal, circumferential, transverse, and radial peak of percentage deformation. Patients with AF were compared with 30 control subjects, paired by age and by sex. Before AF ablation, LV ejection fraction, transverse and radial strains were not significantly different from control subjects. By contrast, global longitudinal and circumferential strains were significantly lower than controls (-17.7%+/-2.4% vs -21.5%+/-2.0% [p<0.01] and -16.0%+/-2.9% vs -20.7%+/-3.4% [p<0.01], respectively). At the end of follow-up, global longitudinal and circumferential strains were significantly improved (-20.8%+/-2.6% vs -17.7%+/-2.4% (p<0.01) and -18.5%+/-3.1% vs -16.0%+/-2.9% [p<0.05], respectively). Global longitudinal strain was not significantly different from normal control subjects at the end of follow-up. In conclusion, this prospective study demonstrates (1) the existence of early longitudinal and circumferential LV systolic function abnormalities in patients with isolated paroxysmal AF but normal ejection fraction and (2) reverse remodeling of these abnormalities after AF ablation.

Cardiac rehabilitation and 5-year mortality after acute coronary syndromes: The 2005 French FAST-MI study.

BACKGROUND Clinical studies have shown a beneficial effect of cardiac rehabilitation (CR) on mortality. OBJECTIVE To study the effect of CR prescription at discharge on 5-year mortality in patients with acute myocardial infarction (AMI). METHODS Participants, from the 2005 French FAST-MI hospital registry, were 2894 survivors at discharge, divided according to AMI type: ST-segment elevation myocardial infarction (STEMI; n=1523) and non-STEMI (NSTEMI; n=1371). The effect of CR prescription on mortality was analysed using a Cox proportional hazards model. RESULTS At discharge, 22.1% of patients had a CR prescription. Patients referred to CR were younger (62.4 vs. 67.5years), were more frequently men and more had presented with STEMI (67.8% vs. 48.3%) than non-referred patients. Ninety-four (14.7%) deaths occurred among patients referred to CR and 585 (25.9%) among non-referred patients (P<0.001). After multivariable adjustment, the association between CR and mortality remained significant (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.60-0.96). Analyses stratified by sex, age (<60 vs.≥60years) and AMI type showed that the inverse association was stronger in men (HR 0.64, 95% CI 0.48-0.87) than in women (HR 0.95, 95% CI 0.64-1.39), in younger (HR 0.34, 95% CI 0.15-0.77) than in older patients (HR 0.84, 95% CI 0.65-1.07) and in NSTEMI (HR 0.63, 95% CI 0.46-0.88) than in STEMI (HR 0.99, 95% CI 0.69-1.40). CONCLUSION After hospitalization for AMI, referral to CR remains a significant predictor of improved patient survival; some subgroups seem to gain greater benefit.

Effect of ivabradine on left ventricular remodelling after reperfused myocardial infarction: A pilot study

BACKGROUND Heart rate is a major determinant of myocardial oxygen demand; in ST-segment elevation myocardial infarction (STEMI), patients treated with primary percutaneous intervention (PPCI), heart rate at discharge correlates with mortality. Ivabradine is a pure heart rate-reducing agent that has no effect on blood pressure and contractility, and can reverse left ventricular (LV) remodelling in patients with heart failure. AIMS To evaluate whether ivabradine, when added to current guideline-based therapy, improves LV remodelling in STEMI patients treated with PPCI. METHODS This paired-cohort study included 124 patients between June 2011 and July 2012. Ivabradine (5mg twice daily) was given promptly after PPCI, along with beta-blockers, to obtain a heart rate<60 beats per minute (ivabradine group). This group was matched with STEMI patients treated in line with current guidelines, including beta-blockers (bisoprolol), according to age, sex, infarct-related coronary artery, ischaemia time and infarct size determined by initial cardiac magnetic resonance imaging (CMR) (control group). Statistical analyses were performed according to an intention-to-continue treatment principle. CMR data at 3 months were available for 122 patients. RESULTS Heart rate was lower in the ivabradine group than in the control group during the initial CMR (P=0.02) and the follow-up CMR (P=0.006). At the follow-up CMR, there was a smaller increase in LV end-diastolic volume index in the ivabradine group than in the control group (P=0.04). LV end-systolic volume index remained unchanged in the ivabradine group, but increased in the control group (P=0.01). There was a significant improvement in LV ejection fraction in the ivabradine group compared with in the control group (P=0.04). CONCLUSIONS In successfully reperfused STEMI patients, ivabradine may improve LV remodelling when added to current guideline-based therapy.

Ventilatory response and peak circulatory power: New functional markers of response after cardiac resynchronization therapy

BACKGROUND The minute ventilation/carbon dioxide production (VE/VCO(2)) slope and peak circulatory power, like peak oxygen consumption (VO(2)), possess strong prognostic values in heart failure but have not been studied after ventricular resynchronization. AIMS In this retrospective study, we evaluated the evolution of ventilatory response, effort capacity, functional status, peak circulatory power and echocardiographic variables, 6 months after cardiac resynchronization therapy (CRT). METHODS Thirty subjects (mean age, 60+/-12 years) underwent symptom-limited exercise testing (CPX) with ventilatory expired gas analysis before and 6 months after CRT. The VE/VCO(2) slope was measured from rest to the end of exercise. Echocardiography was performed in stable clinical and pharmacological conditions. RESULTS Mean New York Heart Association (NYHA) status improved significantly from 2.9 to 1.8 (p<0.001). Significant improvements were seen in exercise tolerance (evaluated by peak VO(2); from 13.1+/-3.1 to 15.3+/-5.6 mL/kg/min, p=0.02), VE/VCO(2) slope (from 44.4+/-19.2 to 39.6+/-13.8, p=0.003) and maximal workload (from 74+/-24 to 82+/-26 W, p=0.02). Mean peak circulatory power improved from 1663+/-494 to 2125+/-1014 mmHgmL/kg/min (p=0.009). Mean left ventricular ejection fraction increased from 25% to 29% (p=0.01). Mean end-systolic and end-diastolic left ventricular volumes decreased significantly from 155 to 128 mL and from 203 to 179 mL, respectively (p<0.05). Mean mitral regurgitation grade improved from 1.4+/-1.0 to 1.1+/-0.9 (p=0.1). No strong correlation was found between echocardiographic changes and improvement in ventilatory efficiency (VE/VCO(2) slope; all r=0.15-0.24). Patients with narrow QRS complexes (<130 ms) did not show significant improvement in functional or echocardiographic variables other than NYHA status. CONCLUSION Cardiac resynchronization therapy improved ventilatory and haemodynamic responses. Our results highlight the potential value of new functional variables such as ventilatory response and peak circulatory power as better markers for identifying responders to CRT.

Successful retrieval of a lost coronary stent from the descending aorta using a loop basket intravascular retriever set

Delivery of a balloon-expandable stent was complicated by a systemic embolisation. The radio-opaque stent was lost in the descending aorta, but then removed by using a loop basket intravascular retriever set without any peripheral arterial complication.

Response to Cardiac Resynchronization Therapy: The Muscular Metabolic Pathway

Background. Changes in peripheral muscle in heart failure lead to a shift from aerobic to early anaerobic metabolism during exercise leading to ergoreflex overactivation and exaggerated hyperventilation evaluated by the VE/VCO2 slope. Methods. 50 patients (38 males, 59 ± 12 years) performed cardio-pulmonary exercise test with gaz exchange measurement and echocardiographic evaluation before and 6 months after CRT. Results. The peak respiratory exchange (VCO2/ VO2) ratio was significantly reduced from 1.16 ± 0.14 to 1.11 ± 0.07 (P < .05) and the time to the anaerobic threshold was increased from 153 ± 82 to 245 ± 140 seconds (P = .01). Peak VO2, VE/VCO2, peak circulatory power and NYHA were improved after CRT (13 ± 4 to16 ± 5 ml/kg/min (P < .05), 45 ± 16 to 39 ± 13 (P < .01), 1805 ± 844 to 2225 ± 1171 mmHg.ml/kg/min (P < .01) and 3 ± 0.35 to 1.88 ± 0.4 (P = .01)). In addition, left ventricular ejection fraction and end-systolic volumes were improved from 24 ± 8 to 29 ± 7% (P < .01) and from 157 ± 69 to 122 ± 55 ml (P < .01). Conclusion. We suggest that CRT leads to an increase in oxidative muscular metabolism and postponed anaerobic threshold reducing exaggerated hyperventilation during exercise.