Patrick Messner-Pellenc

Subclinical Cardiac Abnormalities in Human Immunodeficiency Virus-Infected Men Receiving Antiretroviral Therapy

Although cardiotoxic effects of highly active antiretroviral therapy (HAART) are a growing concern, there is a lack of prospective studies of subclinical involvement of the heart in human immunodeficiency virus (HIV)-infected patients. This study evaluated noninvasively cardiac morphologic characteristics and function in HIV-positive (HIV(+)) men receiving HAART for > or =2 years with no clinical evidence of cardiovascular disease. Echocardiography at rest, including tissue Doppler imaging and exercise testing, were performed in 30 HIV(+) men (age 42.1 +/- 4.7 years, duration of HIV infection 10.4 +/- 4.7 years, duration of HAART 5.3 +/- 2.1 years) and 26 age-matched healthy controls. At rest, HIV(+) patients had similar left ventricular (LV) mass indexed to height(2.7) (40.6 +/- 9.5 vs 37.5 +/- 9.3 g/m; p >0.05), but a higher prevalence of LV diastolic dysfunction (abnormal relaxation or pseudonormal filling pattern in 64% of patients vs 12% of controls; p <0.001). LV systolic function indexes were significantly lower (ejection fraction 60.4 +/- 8.7% vs 66.9 +/- 6.9%; p <0.01, and tissue Doppler imaging peak systolic velocity 11.4 +/- 1.6 vs 13.5 +/- 2.2 cm/s; p <0.001). Pulmonary artery pressure was higher in patients compared with controls (32.1 +/- 5.4 vs 26.1 +/- 6.5 mm Hg; p <0.001). Exercise testing showed decreased exercise tolerance in HIV(+) patients, with no case of myocardial ischemia. In conclusion, subclinical cardiac abnormalities are frequently observed in HIV(+) patients on HAART. The usefulness of systematic noninvasive screening in this population should be considered. GECEM study no. 30: National Agency for AIDS Research (ANRS).

A Case of Cardiomyopathy Induced by Inappropriate Sinus Tachycardia and Cured by Ivabradine

We present the case of a 67‐year‐old woman with cardiomyopathy induced by inappropriate sinus tachycardia (IST) and a particularly high average heart rate. The patient was resistant and/or intolerant to treatment with conventional rate‐slowing medications. We used ivabradine—a specific sinus node If current inhibitor—and successfully lowered the heart rate (33 beats per minute mean heart rate decrease). Symptoms, systolic function, and heart rate variability parameters recovered dramatically. No side effect was noted. We suggest that ivabradine—evaluated in trials to treat stable angina—should be considered as a second‐line treatment in patients with very symptomatic and refractory IST.

Exercise Response in Hypertrophic Cardiomyopathy: Blunted Left Ventricular Deformational and Twisting Reserve with Altered Systolic-Diastolic Coupling

Background— Abnormal left ventricular (LV) deformational mechanics have been demonstrated in patients with hypertrophic cardiomyopathy (HCM) at rest, but there is a lack of information on their adaptation to exercise. The aim of this study was to assess the adaptability of LV strains and torsional mechanics during exercise in HCM patients. Methods and Results— Twenty nonobstructive HCM patients (age, 48.3±12.3 years; 14 men) and 20 control subjects underwent speckle-tracking echocardiographic measurement of longitudinal, radial, and circumferential strains, systolic twist, and diastolic untwisting rate (UTR) at rest and submaximal exercise. HCM patients showed lower resting longitudinal (−15.7±5.0% versus −19.4±2.6%, P<0.001) and radial (38.1±11.3% versus 44.7±14.4%, P<0.05) strains but higher circumferential strain (−21.9±4.0% versus −18.8±2.3%, P<0.05) and twist (15.7±3.6° versus 9.3±2.6°, P<0.0001) than control subjects. Exercise induced an increase in all strains in control subjects but only a moderate increase in longitudinal strain (to −18.4±5.0%), without significant changes in radial and circumferential strains or twist in HCM patients. Exercise peak UTR was lower (−119.0±31.5°/s versus −137.3±41.1°/s) and occurred later (137±18% versus 125±11% systolic time, P<0.05) in HCM than in control subjects. A significant relationship between twist and UTR was obtained in control subjects (ß=−0.0807, P<0.001) but not in HCM patients (ß=−0.0051, P=0.68). Conclusions— HCM patients had severely limited strain adaptability and no LV twisting reserve at exercise. They had reduced and delayed UTR with reduced systolic-diastolic coupling efficiency by twist-untwist mechanics.Background— Abnormal left ventricular (LV) deformational mechanics have been demonstrated in patients with hypertrophic cardiomyopathy (HCM) at rest, but there is a lack of information on their adaptation to exercise. The aim of this study was to assess the adaptability of LV strains and torsional mechanics during exercise in HCM patients. Methods and Results— Twenty nonobstructive HCM patients (age, 48.3±12.3 years; 14 men) and 20 control subjects underwent speckle-tracking echocardiographic measurement of longitudinal, radial, and circumferential strains, systolic twist, and diastolic untwisting rate (UTR) at rest and submaximal exercise. HCM patients showed lower resting longitudinal (−15.7±5.0% versus −19.4±2.6%, P <0.001) and radial (38.1±11.3% versus 44.7±14.4%, P <0.05) strains but higher circumferential strain (−21.9±4.0% versus −18.8±2.3%, P <0.05) and twist (15.7±3.6° versus 9.3±2.6°, P <0.0001) than control subjects. Exercise induced an increase in all strains in control subjects but only a moderate increase in longitudinal strain (to −18.4±5.0%), without significant changes in radial and circumferential strains or twist in HCM patients. Exercise peak UTR was lower (−119.0±31.5°/s versus −137.3±41.1°/s) and occurred later (137±18% versus 125±11% systolic time, P <0.05) in HCM than in control subjects. A significant relationship between twist and UTR was obtained in control subjects (s=−0.0807, P <0.001) but not in HCM patients (s=−0.0051, P =0.68). Conclusions— HCM patients had severely limited strain adaptability and no LV twisting reserve at exercise. They had reduced and delayed UTR with reduced systolic-diastolic coupling efficiency by twist-untwist mechanics.

Myocardial viability assessed by Dobutamine echocardiography in acute myocardial infarction after successful primary coronary angioplasty

Dobutamine echocardiography (5 and 10 microg/kg/ min) was performed in 40 patients 4 +/- 1 days after acute myocardial infarction reperfused by primary coronary angioplasty. The left ventricle was divided into 11 segments. Reversible myocardial dysfunction was indicated by a decrease in at least 2 grades in the total segmental score. Follow-up echocardiography was performed 2 months later. Contractile reserve was documented in 18 patients with dobutamine echocardiography (45%). Sensitivity, specificity, positive, and negative predictive value of dobutamine echocardiography in predicting improvement in contractile function at follow-up were 82%, 83%, 78%, and 86%, respectively. Negative predictive value was high in all dyssynergic segments (86%). Positive predictive value was higher in hypokinetic than in akinetic segments (73% vs 21%; p <0.05). Recovery of wall motion at follow-up was statistically associated with higher left ventricular ejection fraction (p <0.04), collateral blood flow before reperfusion (p = 0.007), and dobutamine responsiveness (p = 0.0001), and was more frequently observed in hypokinetic than in akinetic segments (p <0.05). Thus, low-dose dobutamine echocardiography accurately predicts the extent of irreversibly damaged myocardium early after successful direct coronary angioplasty in acute myocardial infarction.

Transcranial Doppler Detection of Cerebral Microemboli during Left Heart Catheterization

The role of transcranial Doppler ultrasonography (TCD) in individual risk assessment of embolic complications and the development of prevention strategies during coronary angiography remains to be determined. The purpose of this study was to assess the prevalence, time of occurrence and potential significance of microembolic signals (MES) detected with TCD during femoral left heart catheterization. TCD monitoring of the right and left middle cerebral artery was performed in 51 consecutive patients (36 men, 15 women) who were referred for coronary angiography. Percutaneous coronary angioplasty was performed during the same procedure in 16 patients. MES were counted manually during and after (off-line analysis) the procedure. Two patients were excluded from analysis because of the absence of an adequate acoustic temporal window. No neurological event occurred within 24 h in the 49 included patients. MES were detected in all except 2 patients (mean number 17.1 ± 12.8 per patient), mainly during left ventriculography (38%) and contrast media injection into the coronary arteries (55%), suggesting their gaseous origin. There was no statistically significant association between the number of MES and patient age, cardiovascular history and risk factors, or catheterization results. The presence of coronary artery disease was inversely related to the number of MES (15.8 ± 0.3 compared to 21.8 ± 0.2 per patient when a normal angiogram was present; p < 0.05). In conclusion, although asymptomatic microemboli commonly occur during left heart catheterization, the majority of them are probably of gaseous origin, since they occurred predominantly during contrast media injection in this study, and were not related to cardiovascular history or to atheroma risk factors. Because air embolism has been reported to be harmful, attempts to reduce its occurrence during catheter-based procedures could be pertinent.

Postoperative exercise tolerance after aortic valve replacement by small-size prosthesis: functional consequence of small-size aortic prosthesis.

OBJECTIVES The objective of this study was to determine whether a small-size valve prosthesis contributes to exercise intolerance, as assessed by VO2 measurement during an exhaustive cycle ergometer exercise. BACKGROUND The determinants of exercise capacity after mechanical aortic replacement are not well known. The selection of small valve sizes has, however, been described as an independent predictor of exercise intolerance as assessed by exercise duration. Maximal oxygen uptake (VO2max) is a good index of exercise tolerance. METHODS Fourteen patients were eligible, with a mean age of 62 +/- 6 years. Before surgery, the mean left ventricular ejection fraction (LVEF) was 73 +/- 8%. Two valve types with small diameter (19 to 21 mm) were used: Medtronic Hall and St Jude Medical. A healthy sedentary control group (n = 14) paired for age, weight and size was constituted. After one year of follow-up, cardiorespiratory tests were performed. In addition, the gradients through the prostheses were determined by continuous pulse Doppler at rest and immediately after the cardiorespiratory test. RESULTS The exercise tolerance was not significantly different between the control group and patient group: VO2 peak (21.7 vs. 20.4 ml/kg/min; p = 0.42), workloads (115 vs. 93 W; p = 0.13) and ventilatory parameters were similar. The mean and peak gradients at rest and during exercise were not correlated with VO2max. CONCLUSIONS Valve replacement by small aortic prosthesis does not seem to be a factor of exercise intolerance as assessed by VO2max in patients without LVEF dysfunction before surgery.

A DYSAUTONOMIC HEAD-UP TILT TEST PATTERN IN ELDERLY PATIENTS WITH NEUROCARDIOGENIC SYNCOPE

The characteristics of neurocardiogenic syncope (NCS) in elderly patients remain unclear. We compared the hemodynamic profiles of young and older patients with consecutive and positive head‐up tilt tests (HUT). Continuous, noninvasive, and reliable monitoring of arterial pressure (AP) and heart rate (HR) was done throughout 46 consecutive positive HUTs of symptomatic patients. The population (12–82 years old) was divided into two groups: younger patients, Y (n = 25, ≤ 65 years), and older patients, O (n = 21). Changes in AP and HR after the first minute of tilting, during the stable orthostatic phase and during syncope were compared. Except for systolic pressure, baseline hemodynamic parameters were similar in Y and O. No difference appeared in the mean time elapsed before syncope (19 ± 9 vs 22 ± 2 min). Asymptomatic hypotension was observed, only in O, 1 minute after tilting, followed by a progressive fall in the mean AP before syncope (0 ± 0.9 vs −1 ± 0.7 mmHg/min) without HR increase (0.7 ± 1 vs 0 ± 0.6 beats/min). This pressure slope was strongly related to age (r = 0.54, P < 0.001). Hemodynamic recording during HUT identifies a dysautonomic pattern in elderly patients with NCS and the abnormal AP/HR responses to orthostasis may be a feature specific to this population. Although the central mechanism of NCS is common to all ages, the age‐related characteristics of the trigger event may indicate the need for specific management at different ages.

Hypertensive patients with left ventricular hypertrophy have global left atrial dysfunction and impaired atrio-ventricular coupling.

Objective: The aim of this study was to comprehensively investigate left atrial (LA) reservoir, conduit, and booster pump functions, as well as their predictors in patients with primary systemic arterial hypertension (HTN) and left ventricular (LV) hypertrophy. Methods: Thirty patients with HTN and LV hypertrophy, but no history of atrial arrhythmia or heart failure, were compared with 29 normotensive controls. Speckle-tracking echocardiography of the LA wall was used to measure systolic and diastolic strains and strain rates. Early diastolic velocity of transmitral flow/early diastolic mitral annular motion velocity (E/E′)/peak systolic LA strain (S-LAs) was used as an index of LA stiffness. Results: HTN patients had higher LV mass index, impaired LV diastolic function, and higher LA volume index than controls. LA reservoir, conduit, and booster pump functions were significantly lower and LA stiffness was greater. Multiple regression analysis indicated that increased LV mass and LV filling pressures as well as reduced LV strain or E′ were predictors for reduced atrial function. Conclusion: HTN patients showed a significant impairment of the three components of LA function. These changes were correlated with LV hypertrophy and dysfunction, and presumably related to LA fibrotic changes, underlining the importance of LA-LV coupling. The prognostic value of these new speckle-tracking echocardiography-based LA strain indices needs to be evaluated by future studies.

0098: One year incidence and clinical impact of bleeding outcomes in STEMI patients treated by prasugrel or clopidogrel in real life: the BLEED-MI study

Purposes The aim of this study was to evaluate one-year incidence of bleeding events and their impact on compliance in patients admitted for ST Elevation Myocardial Infarction (STEMI) and treated by prasugrel or clopidogrel in « real-world ». Methods Patients admitted for a STEMI were treated by either clopidogrel or prasugrel according to the physician with respect of guidelines. The primary endpoint was the first occurrence of bleeding events within 12 months assessed by the Bleeding Academic Research Consortium (BARC) classification using a dedicated questionnaire focused on bleeding events. Topography bleedings, causes of premature cessation and ischemic events were also compared. Results 390 patients were enrolled, 211 in prasugrel group and 179 in clopidogrel group. Patients in the prasugrel group were younger, with higher body weight and were more frequently men. At 12 months, a bleeding complication occurred in 40% of patients regardless of its severity or treatment prescribed. Major bleedings (BARC 3) were significantly lower with prasugrel than clopidogrel (1% versus 6%, p=0.001). Minimal bleedings (BARC 1) were more frequent in clopidogrel group than prasugrel group (respectively 27% and 18%; p=0.05). However BARC 2 bleedings occurred more often in prasugrel group (14% versus 6%, p=0.01) (figure). Subcutaneous and gastrointestinal haemorraghes were the most frequent. Over one-year, the rate of cessation was 18% in the prasugrel group and only 10% in the clopidogrel group (p=0.04). Respectively for prasugrel and clopidogrel, rates of recommend discontinuation were 10% and 4% (p=0.02) and of disruption were 8% and 5% (p=0.3). Despite more frequent discontinuation, mortality remains very low in the prasugrel group (0.5% versus 7%, p=0.0003). Conclusion In real-world, in a low bleeding risk population, the rate of major bleedings with prasugrel at 12 months was low but nuisance bleedings were frequent with significant impact on premature cessation Download : Download full-size image Abstract 0098 – Figure: 12 months bleedings classification

Exercise Response in Hypertrophic CardiomyopathyClinical Perspective

Background— Abnormal left ventricular (LV) deformational mechanics have been demonstrated in patients with hypertrophic cardiomyopathy (HCM) at rest, but there is a lack of information on their adaptation to exercise. The aim of this study was to assess the adaptability of LV strains and torsional mechanics during exercise in HCM patients. Methods and Results— Twenty nonobstructive HCM patients (age, 48.3±12.3 years; 14 men) and 20 control subjects underwent speckle-tracking echocardiographic measurement of longitudinal, radial, and circumferential strains, systolic twist, and diastolic untwisting rate (UTR) at rest and submaximal exercise. HCM patients showed lower resting longitudinal (−15.7±5.0% versus −19.4±2.6%, P<0.001) and radial (38.1±11.3% versus 44.7±14.4%, P<0.05) strains but higher circumferential strain (−21.9±4.0% versus −18.8±2.3%, P<0.05) and twist (15.7±3.6° versus 9.3±2.6°, P<0.0001) than control subjects. Exercise induced an increase in all strains in control subjects but only a moderate increase in longitudinal strain (to −18.4±5.0%), without significant changes in radial and circumferential strains or twist in HCM patients. Exercise peak UTR was lower (−119.0±31.5°/s versus −137.3±41.1°/s) and occurred later (137±18% versus 125±11% systolic time, P<0.05) in HCM than in control subjects. A significant relationship between twist and UTR was obtained in control subjects (ß=−0.0807, P<0.001) but not in HCM patients (ß=−0.0051, P=0.68). Conclusions— HCM patients had severely limited strain adaptability and no LV twisting reserve at exercise. They had reduced and delayed UTR with reduced systolic-diastolic coupling efficiency by twist-untwist mechanics.Background— Abnormal left ventricular (LV) deformational mechanics have been demonstrated in patients with hypertrophic cardiomyopathy (HCM) at rest, but there is a lack of information on their adaptation to exercise. The aim of this study was to assess the adaptability of LV strains and torsional mechanics during exercise in HCM patients. Methods and Results— Twenty nonobstructive HCM patients (age, 48.3±12.3 years; 14 men) and 20 control subjects underwent speckle-tracking echocardiographic measurement of longitudinal, radial, and circumferential strains, systolic twist, and diastolic untwisting rate (UTR) at rest and submaximal exercise. HCM patients showed lower resting longitudinal (−15.7±5.0% versus −19.4±2.6%, P <0.001) and radial (38.1±11.3% versus 44.7±14.4%, P <0.05) strains but higher circumferential strain (−21.9±4.0% versus −18.8±2.3%, P <0.05) and twist (15.7±3.6° versus 9.3±2.6°, P <0.0001) than control subjects. Exercise induced an increase in all strains in control subjects but only a moderate increase in longitudinal strain (to −18.4±5.0%), without significant changes in radial and circumferential strains or twist in HCM patients. Exercise peak UTR was lower (−119.0±31.5°/s versus −137.3±41.1°/s) and occurred later (137±18% versus 125±11% systolic time, P <0.05) in HCM than in control subjects. A significant relationship between twist and UTR was obtained in control subjects (s=−0.0807, P <0.001) but not in HCM patients (s=−0.0051, P =0.68). Conclusions— HCM patients had severely limited strain adaptability and no LV twisting reserve at exercise. They had reduced and delayed UTR with reduced systolic-diastolic coupling efficiency by twist-untwist mechanics.