Maxime Guenoun

Reduction of procedure duration and radiation exposure with a dedicated inner lumen mapping catheter during pulmonary vein cryoablation.

The Achieve catheter (AC; Medtronic‐CryoCath, Pointe‐Claire, Canada) is a circular mapping catheter introduced through the lumen of the cryoballoon (CB) catheter which is safe and effective to both navigate the CB to the pulmonary veins (PV) and allow PV potential recording during PV cryoablation. The aim of this study was to evaluate the impact of the use of the AC on procedural outcomes.

Cross-ventricular pacemaker-mediated tachycardia by myopotential induction during biventricular pacing.

Background: Patients in permanent atrial fibrillation treated for heart failure and ventricular asynchrony can be implanted with conventional dual chamber pacemakers (DDD) pacemakers used in the biventricular mode. The left ventricular lead is connected to the atrial channel.

Distribution of left ventricular ejection fraction and heart rate values in a cohort of stable coronary patients: The INDYCE registry

BACKGROUND The distribution of left ventricular ejection fraction (LVEF) - a key factor in coronary artery disease (CAD) patient management and prognostication - is poorly documented. OBJECTIVE To determine LVEF and heart rate (HR) values, and describe the management of stable CAD patients in France. METHODS The INDYCE survey was a prospective, multicentre registry of consecutive stable CAD outpatients attending a cardiology consultation. The survey focused on LVEF values measured using the echocardiographic Simpson biplane method. Drug therapy, resting HR, blood pressure and symptoms were also recorded. RESULTS Overall, 3119 patients (68.4 +/- 11.0 years; 80% men) were enrolled. LVEF was 56.1+/-11.8% on average, and was poor (<40%) and moderately impaired (40-50%) in 9.6% (n=298) and 19.8% (n=619) of cases, respectively. Symptomatic angina pectoris was present in 19.2% of cases and only 40.6% of patients were asymptomatic (no angina and NYHA class < or = I) despite relatively aggressive management (79.0% of patients had undergone coronary angioplasty and/or bypass graft). Interestingly, 14.1% of patients with LVEF less than 40% were asymptomatic. In multivariable analysis, LVEF less than 40% was associated most strongly with symptomatic status (odds ratio 3.82; 95% CI 2.59-5.63; P<0.0001), together with female sex, age greater than 75 years, diabetes, HR greater or equal to 70 bpm, sedentariness, obesity and disease duration. CONCLUSION Only 9.6% of stable CAD patients had severe left ventricular dysfunction; among them, 14.1% were strictly asymptomatic. This could justify regular LVEF measurement in CAD patients. Three potentially reversible factors (HR>or=70 bpm, being overweight and sedentariness) were linked independently to the presence of symptoms.

Pulmonary vein isolation using a single size cryoballoon chosen according to transesophageal echocardiography information

BACKGROUND Pulmonary vein isolation (PVI) using cryoballoon (CB) catheter is a new technique for atrial fibrillation (AF) ablation. Previous studies used computer tomography (CT) or magnetic resonance imaging (MRI) scan to determine the pulmonary vein (PV) diameter and anatomy for choosing the CB size. We evaluated pre-ablation transoesophageal-echocardiography (TEE) as an alternative to CT/MRI scan in patients undergoing AF ablation for determining the appropriate size of the CB. METHODS Fifty-five consecutive patients (men=43, women=12) with a mean age of 63 ± 12.5 years, and with drug-refractory paroxysmal AF (34 patients) or persistent AF (21 patients) were included in this prospective study. All patients underwent pre-ablation TEE. RESULTS Hypertension was present in 19 patients (34%). Mean anterior-posterior left atrium diameter was 45.1 ± 8.9 mm. In total, 217 PV were targeted using a single 23-mm (n=14) or 28-mm (n=40) CB catheter chosen according to TEE-obtained measurements. PVI was achieved in 195 PV (90%). Mean number of CB applications per patient was 9.8 ± 2.1 (range 8-14). Mean procedure duration and fluoroscopy times were 131 ± 27 min (90-190 min) and 36 ± 12 min (22-66 min) respectively. Phrenic nerve palsy occurred in 3 patients (5.4%) and was transient (<1 month) in all of them. CONCLUSION This study suggests that TEE is an easily available and effective tool to select the size of the CB for PVI according to evaluated PV diameters and anatomy.

Ambulatory hypertensive patients treated by cardiologists in France.

BACKGROUND While general practitioners treat most hypertensive patients in France, hypertension is the most frequent pathology treated by cardiologists, raising questions about the differing profiles of such patients. Poor control of hypertension is commonly reported, and yet has not improved over time. Better understanding of the determinants of control, at both patient and physician levels, is necessary to implement improvements in practice. AIMS To describe the hypertensive population treated by independent cardiologists in France and to assess the prevalence and determinants of not-at-goal blood pressure (BP), at patient and physician levels. METHODS The COLHYGE study was an observational cross-sectional epidemiological study. Consecutive patients (n=5798) were selected by 371 independent cardiologists in France. Data concerning patients and physicians were assessed. RESULTS Our study population had an elevated cardiovascular risk, high prevalence of patients in secondary cardiovascular prevention (27.5%) and a high proportion of diabetic patients (22.8%). Only 20.8% of the population presented controlled BP. At the patient level, the following variables were negatively and independently associated with BP control: age; body mass index; heart rate; recently diagnosed hypertension; left ventricular hypertrophy; patient belief that they are taking too many pills; prescription of calcium channel blockers, lipid-lowering agents and antiplatelet agents. Presence of atrial fibrillation and the prescription of renin-angiotensin system blockers and fixed combinations correlated positively with BP control. At the physician level, working in big cities and having an exclusive independent practice were associated with good BP control. There was high heterogeneity among physicians in terms of BP control, independent of the patient and physician characteristics assessed. CONCLUSION The COLHYGE study has confirmed a high cardiovascular risk and poor BP control among hypertensive patients treated by cardiologists in France. Strategies aiming to control BP should focus on both patient and physician characteristics.

Noninvasive detection of atrial fibrillation in cryptogenic stroke: Contribution of a new e-cardiology device

This observation justifies larger observational studies to confirm the reliability and durability of the connected garment. Case report We describe the case of a 42-year-old engineer, physically fit with no significant personal or family medical history, who arrived at our emergency department few hours after the sudden onset of diplopia and balance disturbance. Computed tomography angiography did not detect any intracranial bleeding, parenchymal hypodensity, arterial occlusion, or dissection. An ischemic stroke was suspected. Intravenous administration of thrombolytic therapy was withheld because he arrived outside the therapeutic window for its administration. The patient received intravenous administration of 250 mg of acetylsalicylic acid and was admitted to the stroke unit and was managed according to standardized international protocols for acute stroke care. A complete workup for stroke etiology was performed including cerebral magnetic resonance imaging study, which confirmed the presence of recent infarcts in the vertebrobasilar territory (Figure 1). Detailed cardiac investigations revealed the presence of sinus rhythm throughout 72 hours of electrocardiographic ambulatory monitoring and unremarkable transthoracic and transesophageal echocardiograms: atria of normal shapes and sizes, normal left ventricular ejection fraction, absence of valvular abnormalities, and no evidence of patent foramen ovale or aneurysm of the interatrial

0435: Anesthesia in ablation procedures is differently proposed in public and private centers. The French Electra survey

Goal to evaluate routine anesthesia strategy in ablation procedures by French electrophysiologists (EPs). Method A questionnaire was e-mailed to 110 French EP. Results Answers were obtained from 95 EP (86.4%): 25% working in a private center, 75% in a public center. Anesthesiologists are always available in 70.8% of private centers vs 11.4% of public centers. When available, 54.2% are entirely dedicated to electrophysiology in private vs 18.6% in public centers. When an anesthesiologist is not available, sedation is obtained using midazolam associated with nalbuphin (32%), morphine (16%) or fentanyl (9%). Propofol is used occasionally by 29% of EPs (35% in public, 9% in private centers). Nitrous oxide inhalation gas is available in 40% of private and 34.3% of public centers. Private EPs are satisfied with the anesthesiologist strategy in 100% of cases versus only 41% of public EP. A good or very good relationship with anesthesiologists is declared by 92% of private EPs versus only 56% of public EPs. Conclusions Collaboration of anesthesiologists with EPs seems to be more operational in private centers. Deep sedation seems to be used as an alternative when anesthesiologists are not available more often in public centers.

0131: Strategy of anticoagulation in pacemaker and ICD replacement procedure in real life. The French Electra survey

Aim to evaluate routine French implanters strategy in device replacement in patients under anticoagulation for atrial Fibrillation (AF pts). Method A questionnaire was e-mailed to 140 French implanters. Results 102 aswers were obtained. In AF patients, admission is on day of procedure D0 (10%) or D-1(80%) whether pts are on vitamine K antagonist(VKA) or New Oral AntiCoagulant (NOAC). In AF pts under VKA, only 4%bridge to Low Weight Heparine (LWH) or Unfractionated Heparine (UH) while treatment is interrupted without substitution (wos) by 61% and continued without interruption by 32%. In AF pts under NOAC, only 5%bridge to UH or LWH while treatment is interrupted on D-3 (13%), D-2(25%), D-1(44%). When interrupted, NOAC are resumed at D0 (23%), D+1(54%), D+2(10%), D+3(3%). Conclusions Most of implanters hospitalize AF pts at D-1 of replacement procedure. Short discontinuation (VKA, NOAC) or uninterruption (VKA) is prefered to bridging strategy.

181: Cardiac resynchronization device implantation procedure in real life. The French Electra survey

Introduction Cardiac resynchronization therapy (CRT) has been a major breakthrough in cardiac failure management. However, implantation procedure is not standardized. Aim of the study To evaluate routine implantation procedure habits in french practice. Material and methods A survey was e-mailed to 100 French CRT implanters in November 2011. Physicians were interviewed on their own strategy in the center. Answers had to concern the most frequent routine attitude. If appropriate, physicians could answer “no standardized attitude or “other”. Results Among the 62 physicians who answered, 45% practise in a university hospital, 24% in a non-university hospital and 23% in a private institution. The rate of physician implantations is 50/year in 42%, 25% and 33%, respectively. Implantations are performed by a single operator in 49%, and in 43% by two physicians, 16% of implants being done under general anaesthesia. Default CRT-Pacemaker (CRT-P) implantations are right-sided in 18%, left-sided in 51%, unsettled in 20%, and for CRT-Defibrillator (CRT-D) 8%, 82 and 10% respectively. The venous approach is “all cephalic” in 21%, all subclavian in 18% and combined in 62%. First implanted lead is the right ventricular lead (RV) in 74%, and the coronary sinus (CS) lead in 23%. RV lead is placed in apical position in 26% and in septal position in 67%. To catheterize the CS, a sheath isused in first intention in 81%. CS angiography is performed in 90%, with an inflated balloon in 59%. In case of atrial fibrillation with CHA2DS2-vasc 4. Conclusion Most of implantations are performed under local anesthesia. Left sided is prefered, especially in case of CRT-D implantation. Most physicians combine the venous accesses, start with the RV septal lead, and perform a CS angiogram via an inflated balloon. In AF patient, VKA interruption is preferred in low risk patients but not in high risk ones. Few implanters choose VKA substitution.

050 Left ventricular systolic dysfunction in patients with coronary artery disease and normal electrocardiogram: results from INDYCE registry

Background Left ventricular systolic function may be altered in patients with coronary artery disease with or without previous myocardial infarction (MI). However, whether left ventricular ejection fraction (LVEF) is reduced ( Methods and results Echocardiography was performed in the 3119 patients with stable coronary artery disease included in the prospective multicenter INDYCE registry; 875 patients (28%) had a normal ECG. These patients (66 ± 10 years old, male: 79%, BMI: 26 ± 3) had a mean LVEF = 62 ± 8% ( 50%: 91% of the patients). Twenty six percent of them had a previous MI. Eighty four percent of them had undergone coronary revascularisation (CABG: 20% and PCA: 68%), 19% had diabetes, 80% dyslipidemia and 56% high blood pressure; 3% of the patients had been hospitalized for acute heart failure (HF) in the previous year; 39% were symptomatic for dyspnea NYHA class 2 or 3, 14% for angina pectoris. Sixty nine percent of them received betablockers. BMI (p = 0.01), male gender (p = 0.01), dyspnea NYHA class 2–3 (p Conclusions LV systolic function is significantly altered in 9% of patients with stable coronary artery disease with normal ECG in INDYCE registry. Male gender, NYHA class 2–3 and BMI seem to be independently associated with LV systolic dysfunction in this population.