Jean Luc Pasquié

Early Postoperative Assessment of Coronary Artery Bypass Graft Patency and Anatomy: Value of Contrast-Enhanced 16-MDCT with Retrospectively ECG-Gated Reconstructions

OBJECTIVE The objective of our study was to assess early postoperative patency and anatomy of off-pump coronary artery bypass grafts (CABGs) using retrospectively ECG-gated MDCT. CONCLUSION Retrospectively ECG-gated MDCT is a promising noninvasive technique with which to assess early postoperative patency and anatomy of CABGs.

Safety, feasibility, and outcome results of cardiac resynchronization with triple-site ventricular stimulation compared to conventional cardiac resynchronization

BACKGROUND The nonresponder rate to cardiac resynchronization therapy (CRT) may be due to incomplete resynchronization, with dyssynchrony persisting in approximately 30% of patients. We hypothesized that CRT with triple-site ventricular stimulation (TRIV) may improve resynchronization and its outcomes. OBJECTIVE The purpose of this study was to assess the feasibility and safety of TRIV and collected data on clinical outcomes to dimension future studies. METHODS Our pilot randomized trial was designed to assess the safety and feasibility of TRIV with 2 right ventricular leads and 1 left ventricular leads compared to conventional CRT. The primary end-point was the rate of severe adverse events at 6 months. Secondary end-points included functional improvement parameters, quality-of-life (QOL) score, and changes of echocardiographic indices at 6 and 12 months in a subset of patients. RESULTS Seventy-six patients were enrolled at 11 centers and randomized to control or TRIV arm. All implant procedures but one were successful. At 6 months, there was no statistical difference between proportions of patients with at least 1 severe adverse event in both groups (34.1% vs 25.7%, P = .425). There also was no difference between functional improvement parameters, 6-minute walking distances (P = .40), QOL scores (P = .27), and echographic indices. At 12 months, the proportions of patients with a left ventricular ejection fraction gain of more than 5%, 10%, or 15% were significantly superior with TRIV. CONCLUSION TRIV pacing is an effective and safe technique and may provide a greater benefit in ventricular remodeling than conventional CRT. Further studies are needed to assess its long-term benefit.

Image-guided ablation of a ventricular tachycardia originating from the left aortic cusp.

A 76-year-old man was admitted with poorly tolerated ventricular tachycardia (VT, Fig. 1). He had no personal or familial history of ventricular arrhythmias. Baseline electrocardiogram (ECG) was normal. Echocardiography, coronary angiogram, and cardiac magnetic resonance imaging (MRI) showed no evidence of underlying structural heart disease, and there was no evidence of metabolic disorder. Angiographic LVEF was 58%. Electrophysiology (EP) study easily induced the clinical VT with left bundle branch block pattern and vertical axis. R waves in V1 and V2 suggested possible origin from the aortic cusps. An ablation procedure was

Sodium-channel blocker challenge in the familial screening of Brugada syndrome: Safety and predictors of positivity

BACKGROUND Sodium-channel blocker challenge (SCBC) is frequently performed to unmask Brugada syndrome. OBJECTIVE We aim to identify predictors of positivity and complications of SCBC in the setting of familial screening of Brugada syndrome. METHODS All consecutive patients from 2000 to 2014 who benefit from a sodium-channel blocker and belong to a family with at least 2 subjects affected by the syndrome were enrolled and followed prospectively. Data were reviewed by 2 physicians blinded to the clinical and genetic status. RESULTS Of the 672 SCBCs performed in 137 families, 337 (50%) were positive. Multivariate analysis identified ajmaline (odds ratio [OR] 2.98; 95% CI 1.65-4.91) and a significant S wave in lead DII (OR 3.11; 95% CI 2.12-4.58), DIII (OR 2.75; 95% CI 1.78-4.25), or V5 (OR 3.71; 95% CI 2.54-5.44) as predictors of a positive SCBC (P < .0001). Eleven patients (1.6%) presented complications (10 ventricular arrhythmias and 1 atrial flutter), but no deaths occurred. Familial history of complications (OR 41; lower quartile, upper quartile 10, 203; P < .0001), young age (P = .04), and decreased electrocardiographic conduction parameters at baseline (P = .04) were predictors of complications. QRS enlargement during SCBC was not associated with complications. During a median follow-up of 106 months (lower quartile, upper quartile 54, 143 months), 11 life-threatening arrhythmias occurred. CONCLUSION SCBC in the screening of familial Brugada syndrome is safe. The risk of complication is considerably increased in the case of familial history of complicated SCBC, in young patients, and in the presence of decreased electrocardiographic conduction parameters. However, QRS enlargement during the test is not directly related to complications and should not be used to prematurely stop the test unless leading to false-negative results.

Prevalence of type 1 Brugada ECG pattern after administration of Class 1C drugs in patients with type 1 myotonic dystrophy: Myotonic dystrophy as a part of the Brugada syndrome

BACKGROUND Both type 1 myotonic dystrophy (MD1) and Brugada syndrome (BrS) may be complicated by conduction disturbances and sudden death. Spontaneous BrS has been observed in MD1 patients, but the prevalence of drug-induced BrS in MD1 is unknown. OBJECTIVE The purpose of this study was to prospectively assess the prevalence of type 1 ST elevation as elicited during pharmacologic challenge with Class 1C drugs in a subgroup of MD1 patients and to further establish correlations with ECG and electrophysiologic variables and prognosis. METHODS From a group of unselected 270 MD1 patients, ajmaline or flecainide drug challenge was performed in a subgroup of 44 patients (27 men, median age 43 years) with minor depolarization/repolarization abnormalities suggestive of possible BrS. The presence of type 1 ST elevation after drug challenge was correlated to clinical, ECG, and electrophysiologic variables. RESULTS Eight of 44 patients (18%) presented with BrS after drug challenge. BrS was seen more often in men (26% vs 6%, P = .09) and was related to younger age (35 vs 48 years, P = .07). BrS was not correlated to symptoms, baseline ECG, HV interval, results of signal-averaged ECG, or abnormalities on ambulatory recordings. MD1 patients with BrS had longer corrected QT intervals, greater increase in PR interval after drug challenge, and higher rate of inducible ventricular arrhythmias (62% vs 21%, P = .03). Twelve patients were implanted with a pacemaker and 5 with an implantable cardioverter-defibrillator. Significant bradycardia did not occur in any patients, and malignant ventricular arrhythmia never occurred during median 7-year follow-up (except 1 hypokalemia-related ventricular fibrillation). CONCLUSION BrS is elicited by a Class 1 drug in 18% of MD1 patients presenting with minor depolarization/repolarization abnormalities at baseline, but the finding seems to be devoid of a prognostic role.

Precordial Thump in the Catheterization Laboratory Experimental Evidence for Commotio Cordis

A 57-year-old man was admitted to our institution for a diagnostic coronarography. During the right coronary injection (Iomeron 350, Altana Pharma, Le Mee sur Seine, France), complete atrioventricular block occurred for 3 seconds. A precordial thump was performed to restart …

090 - Could heart rate predict duration of hospitalizations for patients admitted for acute pericarditis?

Purpose Acute pericarditis is rather frequent. Annual incidence is estimated to 27.7 new cases per 100,000 inhabitants in Europe. About 5% of all non-ischemic chest pains admitted at emergencies could be pericarditis. Most of the patients are young patients, with a significant cost to society, particularly as regards hospitalizations. Indeed, pericarditis represents 1% of all hospitalizations in department of cardiology. It could be very interesting if clinical presentation and especially heart rate could help predict duration of hospitalizations. Methods Between March 2007 and February 2010, we conducted a retrospective study concerning all patients admitted in our center for acute pericarditis. Diagnosis criteria included 2 among the 4 following: typical chest pain, friction rub, pericardial effusion on echocardiography, or typical ECG findings. We evaluated hospital events (heart failure, acute pains, death) and biology during hospitalization (CRP on admission, on days 1, 2, 3, and especially peak). At one month, clinical events were recorded through phone calls when not noticed in clinical settings. Results We included 73 patients. Mean age was 41.0 y (CI 95% 37.2-44.8) and mean hospitalization duration was 3.5 d (2.5-4.5). Heart rate on admission was 88 bpm (83.6-92.4) and 71.8 bpm (68.9-74.7) on discharge. CRP peak was strongly correlated with heart rate (r=0.54; p Conclusion In acute pericarditis, cardiac frequency at admission is correlated with hospitalization duration, and could be a new prognostic marker. This point deserves to be explored, in order to reduce hospitalization duration. Download : Download full-size image

083 - Medical hypothesis: heart rate on admission and CRP are correlated, in acute pericarditis: a link between heart rate and pericardial inflammation?

Introduction Rest is usually recommended in acute pericarditis, as it could help to lower heart rate (HR) and contribute to limit “mechanical inflammation”. Whether HR on admission could be correlated and perhaps participate to inflammation has not been reported. Methods Between March 2007 and February 2010, we conducted a retrospective study on all patients admitted in our center for acute pericarditis. Diagnosis criteria included 2 among the following: typical chest pain, friction rub, pericardial effusion on cardiac echography, or typical ECG findings. Primary endpoint was biology: CRP on admission, on days 1, 2, 3, and especially peak. We evaluated also recurrences and clinical events during hospitalization and at one month. Results We included 73 patients. Median age was 38.0 y (CI 25-75% 28.0-51.0) and median hospitalization duration was 2.0 d (1.5-3.0). 27% of the patients presented pericardial effusion. Heart rate on admission was 88.0 bpm (CI 25-75%: 76.0-100.0) and on discharge 72.0 (65.0-80.0)). Heart rate on admission was significantly correlated with CRP on admission (r=0.34, n=69; p=0.004), CRP peak (r=0.54; n=61; p Conclusion In acute pericarditis, HR on admission is independently correlated with CRP levels. These observations could suggest a link between HR and pericardial inflammation.

325: Ivabradine and dobutamine associated as a pure inotropic drug in cardiogenic shock?

Introduction Dobutamine remains gold-standard treatment in cardiogenic shock. However, it exacerbates tachycardia, worsening heart failure. Ivabradine, a specific inhibitor of If channel, could reduce this deleterious effect in association with dobutamine in patients with cardiogenic shock. We report the case of a 41-year-old woman admitted in intensive care unit for a severe heart failure with hemodynamic shock. She had no medical history. She suffered from thoracic and epigastric pain and cholecystis was initially diagnosed with an indication of sphincterotomy. However, her clinical status progressively worsened with severe dyspnea and global heart failure requiring appropriate treatment. ECG showed inverted T waves in the lateral leads and echocardiography showed a dilated cardiomyopathy with severe systolic alteration (LVEF: 35%). Coronary angiogram was strictly normal. Finally, no evidence was found on cardiac MRI for ischemic process or myocarditis. She progressively worsened with renal and hepatic dysfunction. Troponin and inflammation markers remained negative. It was necessary to introduce dobutamine and intravenous diuretics but we noticed an initial increase in heart rate concomitantly with blood pressure. We added ivabradine in order to reduce heart rate without effect on blood pressure (fig). Her clinical status improved and dobutamine could be stopped after 5 days and beta-blockers were then introduced. Discussion Heart rate is a well-known marker of prognosis and tachycardia worsened by dobutamine could be deleterious to evolution of patient with cardiogenic shock. Ivabradine could be helpful in reducing heart rate without effect on blood pressure. However, this drug is indicated in stable heart failure but, to this day, hemodynamic instability is excluded. New prospective studies seem necessary to evaluate this benefit. Conclusion In cardiogenic shock, association of dobutamine and ivabradine could be interesting to create a pure inotropic drug. Download full-size image

047 Are the patients benefiting from a coronarography well-informed? Evaluation of written information efficacy

Introduction prior information in the realization of an invasive intervention is crucial. Indeed, the patient has to know theorically his disease, diagnostic and therapeutic means, but also the risks of the used technique. The habits of information vary many from one center to another, in spite of the proposition of an information leaflet written by the French Society of Cardiology. Our aim was to evaluate the efficacy of the written information on patients admitted for coronary arteriography. Methods Among patients hospitalized for realization of a programmed coronarography, a questionnaire was delivered before the information leaflet. Patients are asked questions tested (27 items) before and after the reading of the information sheet (not limited time), about coronarography indication, modalities, benefits, possible complications,… Results 34 patients were included: all knew hospitalization reason, 86% were men, middle-aged 65 (IC95% 60–70). 34% (15–54) had studied in higher education. 97% had had information before. Only 56% (38–74) were informed about the mode of anesthesia, 36% (19–53) duration, 69% (53–86) the injection of iodine, 44% the risk of allergy, 53% the risk of bruise, 15% of the cardiac risks, 21% the renal risks. 71% knew the diagnostic benefits, 44% the possible coronary angioplasty, 17% the eventuality of a bypass surgery. The delivery of the information leaflet didn’t modify the knowledge on most of these items, in particular the modalities and the profits. The risks were known significantly better for the allergy (p = 0.019), the bruise (p = 0.018), the cardiac risks (0.001). Conclusions The population benefiting from a coronarography considers to be enough informed. However, knowledge of the modalities, profits and risks are very low. The delivery of the consensual leaflet doesn’t allow improving the situation, except as far as concerned the complications. Better information is necessary.