Jean Jacques Blanc

ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias)

ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary : a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias).

Evaluation of Different Ventricular Pacing Sites in Patients With Severe Heart Failure Results of an Acute Hemodynamic Study

BACKGROUNDnMultisite ventricular pacing has recently been proposed as an additional treatment for patients with severe congestive heart failure. To further assess the potential value of this technique, we compared the acute hemodynamic changes associated with pacing the right ventricular apex (RVA) or outflow tract (RVOT) alone, the left ventricle (LV) alone, or biventricular (BIV) pacing of the RVA and LV together.nnnMETHODS AND RESULTSnAcute hemodynamic findings were measured in 27 patients with severe heart failure despite optimal therapy and either first-degree AV block and/or an intraventricular conduction defect. In the 23 patients with a high pulmonary capillary wedge pressure (PCWP) (>15 mm Hg), data were collected after transvenous pacing at different ventricular sites in either the VDD mode (AV delay=100 ms) or the VVI mode in patients with atrial fibrillation (n=6). The mean baseline cardiac index was 1.82 L x min(-1) x m(-2). Mean+/-SD baseline systolic blood pressure (SBP) (118.5+/-15.2 mm Hg), PCWP (26.4+/-6.6 mm Hg), and V-wave amplitude (39.1+/-14.6 mm Hg) were similar before and after either RVA or RVOT pacing. In contrast, LV-based pacing (either LV alone or BIV pacing) resulted in higher SBP (P<.03) and lower PCWP (P<.01) and V-wave amplitude (P<.001) than either baseline or RV pacing measurements. With LV pacing alone, SBP, PCWP, and V waves were 126.5+/-15.1, 20.7+/-5.9, and 25.5+/-8.1 mm Hg, respectively. The results with LV pacing alone were similar to those obtained with BIV pacing.nnnCONCLUSIONSnIn patients with severe congestive heart failure, both LV pacing alone and BIV pacing resulted in a similar and significant acute improvement in SBP, PCWP, and V-wave amplitude compared with baseline measurements and RV pacing alone. These results provide a strong basis for initiating long-term studies examining the chronic effects of LV-based pacing in patients with medically refractory congestive heart failure.

Pacemaker Therapy in Patients With Neurally Mediated Syncope and Documented Asystole Third International Study on Syncope of Uncertain Etiology (ISSUE-3): A Randomized Trial

Background— The efficacy of cardiac pacing for prevention of syncopal recurrences in patients with neurally mediated syncope is controversial. We wanted to determine whether pacing therapy reduces syncopal recurrences in patients with severe asystolic neurally mediated syncope. Methods and Results— Double-blind, randomized placebo-controlled study conducted in 29 centers in the Third International Study on Syncope of Uncertain Etiology (ISSUE-3) trial. Patients were ≥40 years, had experienced ≥3 syncopal episodes in the previous 2 years. Initially, 511 patients, received an implantable loop recorder; 89 of these had documentation of syncope with ≥3 s asystole or ≥6 s asystole without syncope within 12±10 months and met criteria for pacemaker implantation; 77 of 89 patients were randomly assigned to dual-chamber pacing with rate drop response or to sensing only. The data were analyzed on intention-to-treat principle. There was syncope recurrence during follow-up in 27 patients, 19 of whom had been assigned to pacemaker OFF and 8 to pacemaker ON. The 2-year estimated syncope recurrence rate was 57% (95% CI, 40–74) with pacemaker OFF and 25% (95% CI, 13–45) with pacemaker ON (log rank: P=0.039 at the threshold of statistical significance of 0.04). The risk of recurrence was reduced by 57% (95% CI, 4–81). Five patients had procedural complications: lead dislodgment in 4 requiring correction and subclavian vein thrombosis in 1 patient. Conclusions— Dual-chamber permanent pacing is effective in reducing recurrence of syncope in patients ≥40 years with severe asystolic neurally mediated syncope. The observed 32% absolute and 57% relative reduction in syncope recurrence support this invasive treatment for the relatively benign neurally mediated syncope. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359203.Background— The efficacy of cardiac pacing for prevention of syncopal recurrences in patients with neurally mediated syncope is controversial. We wanted to determine whether pacing therapy reduces syncopal recurrences in patients with severe asystolic neurally mediated syncope.nnMethods and Results— Double-blind, randomized placebo-controlled study conducted in 29 centers in the Third International Study on Syncope of Uncertain Etiology (ISSUE-3) trial. Patients were ≥40 years, had experienced ≥3 syncopal episodes in the previous 2 years. Initially, 511 patients, received an implantable loop recorder; 89 of these had documentation of syncope with ≥3 s asystole or ≥6 s asystole without syncope within 12±10 months and met criteria for pacemaker implantation; 77 of 89 patients were randomly assigned to dual-chamber pacing with rate drop response or to sensing only. The data were analyzed on intention-to-treat principle. There was syncope recurrence during follow-up in 27 patients, 19 of whom had been assigned to pacemaker OFF and 8 to pacemaker ON. The 2-year estimated syncope recurrence rate was 57% (95% CI, 40–74) with pacemaker OFF and 25% (95% CI, 13–45) with pacemaker ON (log rank: P =0.039 at the threshold of statistical significance of 0.04). The risk of recurrence was reduced by 57% (95% CI, 4–81). Five patients had procedural complications: lead dislodgment in 4 requiring correction and subclavian vein thrombosis in 1 patient.nnConclusions— Dual-chamber permanent pacing is effective in reducing recurrence of syncope in patients ≥40 years with severe asystolic neurally mediated syncope. The observed 32% absolute and 57% relative reduction in syncope recurrence support this invasive treatment for the relatively benign neurally mediated syncope.nnClinical Trial Registration— URL: . Unique identifier: [NCT00359203][1].nn# Clinical Perspective {#article-title-19}nn [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00359203&atom=%2Fcirculationaha%2F125%2F21%2F2566.atom

Long-term follow-up of patients with short QT syndrome.

OBJECTIVESnThe aim of this study was to investigate the clinical characteristics and the long-term course of a large cohort of patients with short QT syndrome (SQTS).nnnBACKGROUNDnSQTS is a rare channelopathy characterized by an increased risk of sudden death. Data on the long-term outcome of SQTS patients are not available.nnnMETHODSnFifty-three patients from the European Short QT Registry (75% males; median age: 26 years) were followed up for 64 ± 27 months.nnnRESULTSnA familial or personal history of cardiac arrest was present in 89%. Sudden death was the clinical presentation in 32%. The average QTc was 314 ± 23 ms. A mutation in genes related to SQTS was found in 23% of the probands; most of them had a gain of function mutation in HERG (SQTS1). Twenty-four patients received an implantable cardioverter defibrillator, and 12 patients received long-term prophylaxis with hydroquinidine (HQ), which was effective in preventing the induction of ventricular arrhythmias. Patients with a HERG mutation had shorter QTc at baseline and a greater QTc prolongation after treatment with HQ. During follow-up, 2 already symptomatic patients received appropriate implantable cardioverter defibrillator shocks and 1 had syncope. Nonsustained polymorphic ventricular tachycardia was recorded in 3 patients. The event rate was 4.9% per year in the patients without antiarrhythmic therapy. No arrhythmic events occurred in patients receiving HQ.nnnCONCLUSIONSnSQTS carries a high risk of sudden death in all age groups. Symptomatic patients have a high risk of recurrent arrhythmic events. HQ is effective in preventing ventricular tachyarrhythmia induction and arrhythmic events during long-term follow-up.

ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death-Executive Summary.

Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death—Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society

Evaluation of left ventricular function and mitral regurgitation during left ventricular-based pacing in patients with heart failure

Beneficial effects of left ventricular (LV)‐based pacing on acute hemodynamic parameters were reported in several series, but only a few studies examined the long‐term effects of this new pacing procedure.

A METHOD FOR PERMANENT TRANSVENOUS LEFT VENTRICULAR PACING

LV‐based pacing has recently been reported to be of benefit in patients with severe cardiac failure and left bundle branch block. LV permanent pacing has been reported using epicardial leads but the surgical mortality is excessive. A transvenous approach is now favored. In this regard, cannulation of the coronary sinus and of one of its tributaries using only the permanent electrode is feasible but technically challenging. We describe a “long guiding sheath” method using catheterization, and a long radiopaque and peelable sheath. Once the coronaiy sinus is cannulated with the electrophysiological catheter, the long sheath is advanced to the mid‐part of the coronary sinus. The permanent pacing electrode is then placed through the sheath and into a tributary of the coronary sinus. This method has been attempted in 10 patients and was successful in 8, with an average lead insertion time of 21 ± 5.5 minutes and an average fluoroscopic time of 11 ± 5.5 minutes. In conclusion, although transvenous left ventricular pacing remains a challenge, the “long guiding sheath” approach appears to facilitate this procedure with both a high success rate and an acceptable procedure time.

Left ventricular-based pacing in patients with chronic heart failure: Comparison of acute hemodynamic benefits according to underlying heart disease

Acute left ventricular‐based pacing has been shown to improve hemodynamics in patients with severe heart failure and left bundle branch block (LBBB). However, it is not known whether the cause of the underlying heart disease influences the potential effect of left ventricular‐based pacing.

Management of patients with palpitations: a position paper from the European Heart Rhythm Association

### Aim of the documentnnPalpitations are among the most common symptoms that prompt patients to consult general practitioners, cardiologists, or emergency healthcare services.1–4 Very often, however, the diagnostic and therapeutic management of this symptom proves to be poorly efficacious and somewhat frustrating for both the patient and the physician. Indeed, in many cases a definitive, or at least probable, diagnosis of the cause of palpitations is not reached and no specific therapy is initiated.5,6 This means that many patients continue to suffer recurrences of their symptoms, which impair their quality of life and mental balance, lead to the potential risk of adverse clinical events, and induce continual recourse to healthcare facilities.nnThese difficulties stem from the fact that palpitations are generally a transitory symptom. Indeed, at the moment of clinical evaluation, the patient is often asymptomatic and the diagnostic evaluation focuses on the search for pathological conditions that may be responsible for the symptom. This gives rise to some uncertainty in establishing a cause–effect relationship between any anomalies that may be detected and the palpitations themselves. Moreover, as palpitations may be caused by a wide range of different physiological and pathological conditions, clinicians tend to apply a number of instrumental investigations, laboratory tests, and specialist examinations, which are both time-consuming and costly. Comparable, for example, to syncope, such an approach is warranted in selected patients, whereas other patients with palpitations may not require such careful follow-up. The initial clinical assessment should, therefore, include an educated estimation of the likelihood of a relevant underlying arrhythmia in a patient with palpitations (‘gatekeeper function).nnThe current management of patients with palpitations is guided chiefly by the clinical experience of the physician. Indeed, the literature lacks specific policy documents or recommendations regarding the most appropriate diagnostic work-up to be adopted in individual …

Consensus document on antithrombotic therapy in the setting of electrophysiological procedures

Guidelines and Expert Consensus documents are proposed to help physicians to select the best possible diagnostic or therapeutic strategies for an individual patient with a specific disease. Recommendations issued from these documents are based on an extensive review of the literature and on discussions among experts when hard data are incomplete or missing. It has been shown that patient outcomes improve when guidelines recommendations are applied in clinical practice. Publication and promotion of these guidelines is one of the most important tasks of scientific societies. The recently created European Heart Rhythm Association (EHRA) wants to meet this commitment in its specific field of competence and one assignment of the scientific committee of EHRA is to propose and promote Guidelines in the management of heart rhythm disturbances not already covered by the European Society of Cardiology (ESC).nnElectrophysiological studies (EPSs), whether or not associated with therapeutic procedures (ablation using different sources of energy or reduction of tachycardia), show the percutaneous introduction of one or multiple catheters to record the electrical activity of the heart or to pace its different cavities. The introduction and manipulation of these catheters in arteries, veins, or cardiac cavities have multiple pathophysiological consequences and one of the most evident is to activate the coagulation cascade with the risk to induce new clots or to mobilize pre-existing ones. Furthermore, withdrawal of catheters induces haemorrhage usually limited by the compression of the site of venous or arterial puncture.nnThere is also a close relationship between EPS and thrombus formation (thrombogenesis) and thus, rhythmologists need to balance the risks between thrombo-embolism and bleeding. There are no guidelines on the use of antithrombotic therapies in the setting (before, during, and after) of EPS. Generally, different laboratories have their own approaches to this clinical problem.nnThe aim of the present document is …