Sophie Tassan-Mangina

Risk factors for infection of implantable cardiac devices: data from a registry of 2496 patients

AIMS The increased use of implantable cardiac devices has been accompanied by an increase in infection. However, risk factors for infection of implanted devices are poorly documented. We aimed to identify risk factors in patients with long-term follow-up after implantation of cardiac devices. METHODS AND RESULTS Patients with first implantation of a cardiac device in our centre between October 1996 and July 2007 were entered in a registry. Each confirmed infection of the implanted device was matched to two controls for age, sex, and implantation year. We recorded cardiovascular risk factors (hypertension, diabetes), previous history of heart disease, renal failure, antiplatelet or anticoagulant therapy, as well as pre- and post-procedural characteristics (antibiotic prophylaxis, hyperthermia, number of leads, associated interventions, and early complications). During the study period, 2496 patients underwent implantation of a cardiac device; 35 infections were diagnosed (1.2%). Among these, 75% occurred during the first year after implantation. Early non-infectious complication requiring surgical intervention was observed only in patients with infection (9 of 35, P < 0.001). Factors independently associated with infection were diabetes [odds ratio (OR) 3.5, 95% confidence interval (CI) [1.03, 12.97]], underlying heart disease (OR 3.12, 95% CI [1.13; 8.69]), and use of >1 lead (OR 4.07, 95% CI [1.23, 13.47]). These latter two risk factors were also independently associated with occurrence of infection within 1 year of implantation. CONCLUSION Our data show that the presence of diabetes and underlying heart disease are independent risk factors for infection after cardiac device implantation. As regards procedural characteristics, the use of several leads and early re-intervention are associated with a higher infection rate.

Minimizing exposure to radiation in invasive cardiology using modern dose-reduction technology: evaluation of the real-life effects

We aimed to measure the reduction in the estimated dose of radiation received by patients that can be achieved using dose‐reduction technology (ClarityIQ, Philips Healthcare, The Netherlands), among all patients undergoing invasive cardiology procedures.

Trends in Patient Exposure to Radiation in Percutaneous Coronary Interventions Over a 10-Year Period

Technological progress has made it possible to reduce the dose of radiation delivered by medical x-ray systems. In parallel, interventional coronary procedures have become increasingly complex and consequently, last longer. This study aimed to compare the estimated dose of radiation received by patients in interventional cardiology at 10 years interval (2006 vs 2016). The study population included all patients who underwent interventional coronary procedures in one of the catheterization laboratories of our institution during 2 periods, namely, period 1 from October 2005 to March 2006, and period 2 from November 2015 to October 2016. The primary end point was the estimated dose of radiation received by the patient as assessed by dose area product. In 2016, the estimated dose of radiation received by patients who underwent interventional coronary procedures was on average 78% lower than that received in 2006 (p <0.0001), whereas the fluoroscopy time increased by 54% on average over the same period (p <0.0001). By multivariate analysis, including age, approach, body mass index, fluoroscopy time, and performance of angioplasty, the reduction in radiation remained significant. The radial approach was significantly associated with an increased estimated dose of radiation received (p <0.0001). In conclusion, the estimated dose of radiation received by patients who underwent interventional cardiology procedures has been reduced by 78% over the last decade.

Effect of Modern Dose-Reduction Technology on the Exposure of Interventional Cardiologists to Radiation in the Catheterization Laboratory

Interventional cardiologists are exposed to deterministic and stochastic effects of ionizing radiation, as evidenced by their increased risk of developing cataracts and left-sided brain tumors, respectively [(1–3)][1]. The ClarityIQ dose-reduction system (Philips Healthcare, Amsterdam, the

Reduction in exposure of interventional cardiologists to ionising radiation over a 10-year period

Exposure of operators to ionising radiation in interventional cardiology has likely diminished, but data confirming the magnitude of the reduction are lacking. The aim of this study was to compare the dose of radiation received by interventional cardiology operators at 11 years interval (2006 vs 2017). The study population comprised all interventional coronary procedures performed by a single operator in one catheterization laboratory (cathlab) of a large university hospital in north-eastern France. Exposure was compared between two periods, namely period 1 (from October 2005 to March 2006) and period 2 (from March 2017 to June 2017). The primary endpoint was the dose of radiation received by the operator, measured using an electronic dosimeter placed on the operators left arm. In 2017, the dose of radiation received by the operators was, on average, 95% lower than the dose received in 2006 (p < 0.0001), even though the average fluoroscopy time increased by 73% over the same period (p < 0.0001). By multivariable analysis including body mass index, fluoroscopy time and performance of at least one (1) coronary angioplasty, the reduction in the operators exposure to radiation remained significant. The dose of radiation received by interventional cardiology operators has decreased by 95% over the last ten years.

Acute coronary syndromes in the very elderly: short term prognostic performance of the SYNTAX score

Acute coronary syndromes (ACS) frequently occur in elderly subjects. The high mortality associated with ACS in this population justifies the identification of factors related to poor prognosis. We aimed to evaluate the short-term prognostic performance of the SYNTAX score in a population of patients aged 85years or more presenting ACS and undergoing coronary angiography. Secondary objectives were to identify factors related to length of stay and potential markers of in-hospital death. We performed a retrospective, single-centre prognostic study including patients aged 85years or more who underwent coronary angiography for ACS over a 4year period. The primary endpoint was length of stay, and the secondary endpoint was in-hospital mortality. In total, 70 patients were included (37 men), average age 87.0±2.5years. Average SYNTAX score was 19.0±14.9. Average length of stay was 13.1±7.8days. By multivariate analysis, SYNTAX score was correlated with length of stay (p=0.008). Seven (10%) patients died in-hospital. Patients who died had a higher SYNTAX score (p=0.013) (threshold value of 25) and a lower left ventricular ejection fraction (p=0.001). They more frequently had signs of heart failure at admission (p=0.002), ST segment elevation ACS (p=0.046) and left main stem involvement (p=0.041) than survivors. In our study, SYNTAX score was associated with length of stay and in-hospital mortality. A SYNTAX score of 25 or more seems to be an indicator of poor short-term prognosis in very elderly patients with ACS.

0218: Comparison of transvenous versus surgical implantation of left ventricular lead for cardiac resynchronization therapy

Background Approximately 1% of the adult population have heart failure with reduced ejection fraction. Since the 1980s, therapeutic advances in this field have been significant, particularly through the development of cardiac resynchronization therapy (CRT). However, transvenous implantation of the left ventricular (LV) lead is unsuccessful in 5 - 15% of patients. For this group, surgical placement of LV lead is an alternative. Objective Compare the effects of transvenous versus surgical implantation of the LV lead in CRT. Methods We included 100 consecutive patients who had received CRT in our centre between January 2008 and July 2012 in a retrospective observational study. Twelve patients who had failed transvenous implantation of LV lead had a surgical placement. Results Population characteristics were a mean age of 66±11 years, 16% female, New York Heart Association class 2.9±0.5, 45% ischemic cardiomyopathy, left ventricular ejection fraction (LVEF) 24±7%, QRS width 165±23ms. There were no major difference in preoperative variables between two groups except sex category (12.5% female in transvenous group versus 42% in surgical group, p=0.022). During a mean follow-up of 508±429 days, the improvements seen in all variables showed no difference between the groups. At six months, 77% of patients had improved at least one class of their dyspnea stage, LVEF improved significantly (24±7% versus 36±10% at six months). Conclusions Surgical placement of LV lead offers similar benefits as compared with transvenous implantation.

198: Patients over 75 years of age with and without atrial fibrillation: characteristics and differences in a hospital cohort of 357 patients

Introduction Characteristics of patients with atrial fibrillation (AF) are well known, however the patients included in published studies are usually younger than patients encountered in daily practice in hospital. Method We performed a prospective observational study which aimed to describe all patients over 75 years hospitalized in a cardiology department. For each patient we collected cause of hospitalisation, medical and cardiovascular history. We compared patients with and without previous history of AF (“AF group” versus “sinus group”). Results Among 1050 patients admitted during an inclusion period of 4 months, 357 patients were older than 75 years: 150 in the “AF group” and 207 in the “sinus group”. AF was paroxysmal, persistent and permanent respectively in 21%, 30%, and 48% of cases. Table – Main data TOTAL N=357 AF group N=150 (42%) Sinus group N=207(58%) p Age 82±13 83±13 81±11 0.03 Men 186 75 (50) 106 (51.2) 0.9 HTA 178 (50) 76 (50.7) 102 (49.5) 0.9 Diabetes 86 (24.1) 35 (23.3) 51 (24.7) 0.1 Dyslipemia 93 (26.1) 35 (23.3) 58 (28.2) 0.3 Ischemic heart disease 13 (38.8) 55 (36.7) 83 (40.3) 0.1 Respiratory failure 26 (7.28) 13 (8.6) 13 (6.28) 0.4 Valvular heart disease 38 (10.5) 20 (13.3) 18 (8.73) 0.04 Pulmonary embolism 20 (5.6) 13 (8.6) 7 (3.3) 0.02 AVC 39 (10.9) 23 (15.3) 16 (7.7) 0,01 Thyroid disease 32 (8.9) 18 (12) 14 (6.7) 0.03 Dementia 23 (6.5) 13 (8.7) 10 (4.9) 0.1 Alcoholism 11 (3) 10 (6.7) 1 (0.48) 0.01 Main cause of hospitalisation Cardiac heart failure 111 (31) 67 (44.7) 44 (21.4) Acute coronary syndrome 67 (19) 11 (7.3) 56 (26.6) Conclusion Patients over 75 years of age accounted for 34% of patients admitted in our cardiology department and 42% of them had a history of atrial fibrillation. AF patients had more frequently valvular disease, thyroid dysfunction, which are comorbidities associated with AF but also more strokes, dementia and hospitalization for heart failure which may be consequences of AF.

197: Oral anticoagulation therapy in older patients with atrial fibrillation: an evaluation of daily practice with regard to guidelines and scores in a cohort of 142 patients

Introduction Age is a major thrombo-embolic risk factor in atrial fibrillation (AF), but also a risk factor for bleeding under oral anticoagulation therapy (OAC). However, it appears that older patients are inadequately treated with OAC. The objective of our study was to evaluate the use of OAC in elderly patients hospitalised in a cardiology department according to current guidelines. Method Over a 4-month period, 142 patients over 75 years old with history of AF were included. Clinical and biological data were recorded, and risk scores for bleeding (HASBLED) and thrombo-embolic events (CHADS2 and CHA2DS2VASc) were independently assessed after discharge. The differences between bleeding and thrombo-embolic risk were calculated for each patient. Patients with OAC at discharge and patients without OAC were compared. Results Mean age was 83±13 years (75 men). Mean CHADS, CHADSVASc and HASBLED scores were respectively 2,6±0,1, 4,6±0,1 and 2,3±0,1. According to CHADSVASc score and guidelines all of the patients were eligible for OAC. However 47.8% of patients were not under OAC. Those patients were older (84.6±0.6 vs. 81.8±0.5; p=0.001), predominantly female (66 vs. 35%; p=0.001) with a higher serum creatinine (127.3±7.3 vs. 106±6.3; p=0.03) and HASBLED score (2.7 vs. 2.16; p=0.001). OAC use was not associated with CHADS and CHADSVASc scores values. OAC No OAC T (CHADS) >B 49.2% 39% * T (CHADS) 2.3% μ 9.2% T (CHADSVASC) >B 47% 40% * T (CHADSVASC) 3.8% μ 8.4% T Thrombo-embolic risk; B: bleeding risk (HASBLED) according to scores * undertreated patients according to scores μ over-treated patients according to scores Conclusion Our study in daily pratice confirms that OAC in older patients with AF are underused and that the bleeding risk may be over-rated and/or thrombo-embolic risk under-estimated. However, specific risk factors in older patients may not be included in currently used scores.