Remote patient monitoring for chronic heart failure in France: When an innovative funding program (ETAPES) meets an innovative solution (Satelia® Cardio).

Introduction: Remote patient monitoring (RPM) is a telehealth activity to collect and analyze patient health or medical data. Its use has expanded in the past decade and has improved medical outcomes and care management of non-communicable chronic diseases. However, implementation of RPM into routine clinical activities has been limited. The objective of this study was to describe the French funding program for RPM (known as ETAPES) and one of the RPM solution providers (Satelia®) dedicated to chronic heart failure (CHF). Methods: A descriptive assessment of both the ETAPES funding program and Satelia® RPM solution was conducted. Data were collected from official legal documents and information that was publicly available online from the French Ministry of Health. Results and Discussion: ETAPES was formally created in 2016 based on previous legislation pertaining to the national health insurance funding strategy. However, it only started to operate in 2018. Patients with CHF were only eligible if they were at medium or high risk of re-hospitalization with a New York Heart Association (NYHA) score superior or equal to two and a BNP>100 pg/ml or NT pro BNP>1000 pg/ml. Medical monitoring was supported through the therapeutic education of a patient on the RPM model of care with a minimum of three training sessions during the first six months. The use of Satelia® Cardio is noteworthy since it relies only on symptomatic monitoring through which the patient manually reports their information by answering a simple questionnaire on a regular basis and does not rely on any connected devices. Conclusion: Innovative funding programs and solutions for RPM need real-world evaluation in the future.

An automated four-point scale scoring of segmental wall motion in echocardiography using quantified parametric images.

The aim of this paper is to develop an automated method which operates on echocardiographic dynamic loops for classifying the left ventricular regional wall motion (RWM) in a four-point scale. A non-selected group of 37 patients (2 and 4 chamber views) was studied. Each view was segmented according to the standardized segmentation using three manually positioned anatomical landmarks (the apex and the angles of the mitral annulus). The segmented data were analyzed by two independent experienced echocardiographists and the consensual RWM scores were used as a reference for comparisons. A fast and automatic parametric imaging method was used to compute and display as static color-coded parametric images both temporal and motion information contained in left ventricular dynamic echocardiograms. The amplitude and time parametric images were provided to a cardiologist for visual analysis of RWM and used for RWM quantification. A cross-validation method was applied to the segmental quantitative indices for classifying RWM in a four-point scale. A total of 518 segments were analyzed. Comparison between visual interpretation of parametric images and the reference reading resulted in an absolute agreement (Aa) of 66% and a relative agreement (Ra) of 96% and kappa (κ) coefficient of 0.61. Comparison of the automated RWM scoring against the same reference provided Aa = 64%, Ra = 96% and κ = 0.64 on the validation subset. Finally, linear regression analysis between the global quantitative index and global reference scores as well as ejection fraction resulted in correlations of 0.85 and 0.79. A new automated four-point scale scoring of RWM was developed and tested in a non-selected database. Its comparison against a consensual visual reading of dynamic echocardiograms showed its ability to classify RWM abnormalities.

Assessment of left ventricular contraction by parametric analysis of main motion (PAMM): theory and application for echocardiography.

The computerized study of the regional contraction of the left ventricle has undergone numerous developments, particularly in relation to echocardiography. A new method, parametric analysis of main motion (PAMM), is proposed in order to synthesize the information contained in a cine loop of images in parametric images. PAMM determines, for the intensity variation time curves (IVTC) observed in each pixel, two amplitude coefficients characterizing the continuous component and the alternating component; the variable component is generated from a mother curve by introducing a time shift coefficient and a scale coefficient. Two approaches, a PAMM data driven and a PAMM model driven (simpler and faster), are proposed. On the basis of the four coefficients, an amplitude image and an image of mean contraction time are synthesized and interpreted by a cardiologist. In all cases, both PAMM methods allow better IVTC adjustment than the other methods of parametric imaging used in echocardiography. A preliminary database comprising 70 segments is scored and compared with the visual analysis, taken from a consensus of two expert interpreters. The levels of absolute and relative concordance are 79% and 97%. PAMM model driven is a promising method for the rapid detection of abnormalities in left ventricle contraction.

Rho GTPases and the control of the oxidative burst in polymorphonuclear leukocytes.

Stimulation of quiescent leukocytes activates the NADPH oxidase, a membrane-associated enzyme system that generates superoxide and other reactive oxygen species (ROS) that are used to kill bacteria within the phagosome. This chapter describes this multicomponent NADPH oxidase system, one of the first cellular systems shown to be directly regulated by Rac GTPases. We present current models of NADPH oxidase regulation by Rac2 and describe how Rac2 activation controls the timing of ROS production in adherent neutrophils. The antagonistic role that Cdc42 plays as a competitor of Rac2 for binding to the cytochrome component of the NADPH oxidase is discussed as a possible mechanism for tonic regulation of ROS production during the formation of the phagosome. Finally, we briefly depict mechanisms by which invasive bacteria can alter (inhibit) NADPH oxidase function, focusing on the effects of invasive bacteria on components and assembly of the NADPH oxidase.

[1/1 nodo-ventricular conduction atrial flutter with amiodarone]. / Flutter atrial à conduction nodovenhiculaire 1/1 sous amiodarone.

1/1 atrial flutter is a regularly described complication of class I anti-arrhythmics. It is, however, very rarely encountered with class III anti-arrhythmics because prolongation of the atrio-ventricular node refractory period prevents 1/1 nodo-ventricular conduction. There have only been seven cases of 1/1 atrial flutter with amiodarone reported in the literature. Here we describe a new case of 1/1 atrial flutter with amiodarone. Our case clearly illustrates not only the different pro-arrhythmic effects of amiodarone (prolongation of the flutter cycle, and infra-Hissian block) but also the pathophysiological mechanisms possible with 1/1 conduction (prolongation of the flutter cycle, considerable permeability of the AV node). It demonstrates the difficulties of diagnosing such a rhythm disturbance, and that it is sometimes poorly tolerated, as well as underlining the importance of early diagnosis (in this case by oesophageal recording). Preventive treatment of 1/1 flutter can include amiodarone, digitalis, a betablocker or a bradycardic calcium inhibitor.

[Echographic calculation of left ventricular mass in TM mode]. / Calcul échocardiographique de la masse ventriculaire gauche en mode TM. Evaluation de nouvelles techniques d'imagerie.

UNLABELLED: TM sections of the left ventricle (LV) have only been validated in fundamental (F) imaging. We were interested in evaluating the repercussions of new imaging techniques, harmonic (H) and colour tissue Doppler (CTD), on the TM measurement of left ventricular mass (LVM), the reference imaging being F imaging. METHOD: We performed a prospective study, including 26 patients with a valid TM section. The LV and LVM parameters in F, H and CTD mode according to the Penn and ASE conventions as well as the inter-observer reproducibility were studied. RESULTS: The correlations for the LVM measurements between F and H, and between F and CTD were high whichever convention was used (r>0.95, p<0.0001). For each observer, the LVM in H and in CTD was always greater than the LVM in F with both conventions (p<0.02). A false diagnosis of LV hypertrophy was made in 27% of patients in H and in 15% of patients in CTD. The best inter-observer reproducibility was obtained in H: the average inter-observer difference (gr.) was 23+/-15 for H, 32+/-19 for F and 59+/-18 for CTD. CONCLUSION: H and CTD imaging entail an overestimation of LVM, essentially by overestimation of the parietal thickness of the LV. The inter-observer reproducibility was excellent in H and poor in CTD. The use of the harmonic mode for LVM calculation must be validated using new formulae.

[Image analysis in contrast echocardiography]. / Les traitements d'image en échocardiographie de contraste.

The visualization of contrast agents in echocardiography is obtained with complex acquisition sequences and their analysis is dependent on operator experience. In order to be more accessible, images analysis is essential and the main objective is to integrate qualitative and quantitative data in one single image.

[Value of factor analysis in a wall motion study: preliminary application in the detection of left ventricular segmental contraction ischemic disorders by echocardiography]. / Apport d'une analyse factorielle à l'étude de mouvements: application préliminaire à la détection par échocardiographie des troubles de la contraction segmentaire du ventricule gauche ischémique.

PURPOSE: Factor Analysis of Medical Image Sequences (FAMIS) was tested to study the regional wall motion of the left ventricle at echocardiography. MATERIALS AND METHODS: FAMIS analyzed the time signal curves of each pixel. One flat curve and one curve describing the contraction-relaxation of the left ventricle were first estimated. The contributions of the curve of each pixel to the two previous curves were computed, yielding two "factor images". The spatial distribution of positive and negative coefficients of the second factor image was analyzed. The evaluation was carried out on 222 segments (20 patients, 18 parasternal short-axis views, 17 apical four-chamber views, and 15 apical two-chamber views). A first echocardiographer reviewed the factor images and the reading was compared to the conventional reading of the cine-loops by two other echocardiographers. Each segment was scored as normal, hypokinetic, akinetic, or dyskinetic. RESULTS: On normal segments, the positive coefficients of the second factor image were on the inner side, the negative coefficients were on the outer side. Dyskinesis yields the opposite pattern. Hypokinesis and akinesis give intermediate images. An absolute concordance was obtained on 71.2% of all segments between the two types of reading. Larger discrepancies were found for akinetic and hypokinetic segments. CONCLUSION: FAMIS is a promising tool to study regional wall motion of the left ventricle.

[Changes in left ventricular torsion during ischemia-reperfusion]. / Altérations de la rotation systolique du ventricule gauche au cours de l'ischémie-reperfusion.

We aimed to characterise the alterations of left ventricular twist during ischaemia-reperfusion and to study their relationship to global left ventricular function. Systolic left ventricular twist was measured at the mid-papillary muscle level by colour tissue Doppler echocardiography in 7 anaesthetised open-chest dogs at baseline, 90 min-occlusion of the left anterior descending, and 180 min after reflow. Tissue Doppler was also performed in 34 patients after anterior infarct and in 20 controls. In controls, rotation occurred counterclockwise when viewed from the base. In a random subset of subjects, the assessment of ventricular twist by tissue Doppler was validated against magnetic resonance myocardial tagging. Myocardial ischaemia led to a decrease in ventricular twist in dogs and infarct patients (p < 0.01). This decrease was correlated with the extent of the asynergic area and global left ventricular function (p < 0.001). In dogs, cardiac twist was higher after reflow relative to ischaemia (p < 0.01). Thus, acute myocardial ischaemia is responsible for a decrease in left ventricular twist that is related to global ventricular function. Colour tissue Doppler echocardiography provides straightforward assessment of left ventricular twist in humans.

Multigate doppler signal analysis using 3-D regularized long AR modelling.

Autoregressive (AR) modelling has already been proposed as an alternative to fast Fourier transform to process ultrasound (US) Doppler signals. Previous works introduced long AR models, set up under a regularization framework. The latter may be in 1-D (frequency) or 2-D (frequency and space or time). This study generalizes the spectrum regularization in the three dimensions frequency, space and time. The problem of the penalization function is addressed, and a new convex solution is proposed, taking into account possible nonstationarity of the Doppler signal. The parameter tuning is based on simulations using a standard Doppler signal model. The first results show that this processing improves the spectral estimation, and is well suited to flow interpretation.

Determinants of right ventricular pressure in mild hypertension.

OBJECTIVE: Doppler echocardiography was used to define reference values and determinants of tricuspid regurgitation peak velocity (TRV) in hypertensive patients. A TRV value > 2.5 m/s is the threshold usually defining abnormal right ventricular systolic pressure. DESIGN AND PATIENTS: Doppler echocardiography was performed in 320 consecutive uncomplicated hypertensive patients, without overt pulmonary or heart disease. Doppler echocardiography included LV mass measurement, LV inflow and pulmonary venous flow analysis, LV systolic function and TRV measurements. RESULTS: Among 320 patients, 255 had normal TRV < 2.5 m/s and 65 had elevated TRV > or = 2.5 m/s. Compared with the normal TRV group, the elevated TRV group was older (60 versus 50 years, P < 0.0001), systolic blood pressure was higher (156 versus 151 mmHg, P = 0.02) and antihypertensive therapy was more frequent (68 versus 51%, P = 0.02); indexed LV mass was higher (45.4 versus 40.6 g/m2.7, P = 0.001), pulmonary D wave peak velocity was higher (42 versus 38 cm/s, P = 0.03). In univariate analysis, age was the most predictive variable of TRV (r = 0.36). In multivariate analysis, three variables were independently related to TRV: age, LV mass, pulmonary D wave (multiple r = 0.47). CONCLUSION: In mild hypertension, TRV is independently related to age, and to a lesser extent, to LV morphology and LV filling pressure. In clinical practice, age should be taken into account to interpret TRV.

In vitro quantification of flow using continuous infusion of Levovist and pairs of harmonic power Doppler images.

To evaluate the potential of harmonic power Doppler to quantify perfusion using a continuous infusion of contrast, two dialysis cartridges were perfused with different flow rates adjusted between 0 to 300 mL/min, corresponding to flow ratios comprised between 300:0 and 150:150. The contrast agent (Levovist, Schering) was injected at constant rates (0.6 to 5 g/h). Sequential pairs of images showing simultaneously the cross-sections of the two filters were acquired with a HDI 5000 (ATL) and the Doppler data were processed with HDI lab software (ATL). The absolute values of the signal in the different regions-of-interest (ROI) were not closely related to flow rate. At the opposite, the rapid signal decrease between the first and the second image of each pair was inversely proportional to the flow rate. An index of perfusion [PerI = image 1/(image 1 -- image 2)] was defined. It correlated closely with the absolute and relative flow rates. For the latter, the slopes of regression were found to be independent of the infusion rate of Levovist. Thus, the use of pairs of images combined with a continuous infusion of Levovist provide a quantification of perfusion.

New diagnostic criteria for diabetes and coronary artery disease: insights from an angiographic study.

OBJECTIVES: The goal of this research was to study coronary atherosclerosis in patients with type 2 diabetes compared with patients without diabetes according to the new definition of diabetes advocated by the American Diabetes Association in 1997. BACKGROUND: Patients with diabetes (fasting plasma glucose above 7.0 mM/L) have a higher risk of cardiovascular death. The correlation with the pattern and severity of their coronary atherosclerosis, especially in the new patients with "mild" diabetes (7.0 mM/L < or = fasting plasma glucose < 7.8 mM/L), remains unclear. METHODS: A cohort of 466 patients undergoing coronary angiography but free of any previous infarction, coronary intervention and insulin therapy were prospectively recruited. Ninety-three had diabetes (fasting plasma glucose > 7.0 mM/L or hypoglycemic oral treatment). Five angiographic indexes were calculated to describe severity and extent of coronary atherosclerosis. RESULTS: Overall, patients with diabetes had more diffuse coronary atherosclerosis, a greater prevalence of mild, moderate and severe stenoses and a two-fold higher occlusion rate than patients without diabetes, even after adjustment for age, gender, body mass index, hypertension, lipid parameters, smoking, family history of cardiovascular events and ischemic symptoms. Patients with "mild diabetes" had a coronary atherosclerosis pattern more similar to patients with normal fasting plasma glucose than to patients formerly defined as diabetic according to the World Health Organization criteria, except that they had a higher prevalence of <50% stenoses. CONCLUSIONS: In patients with type 2 diabetes, those with 7.0 mM/L < or = fasting plasma glucose < 7.7 mM/L have a slightly greater prevalence of mildly severe lesions that may partly explain their higher cardiovascular event rate.

Molecular basis for Rac2 regulation of phagocyte NADPH oxidase.

A Rac GTPase-regulated multiprotein NADPH oxidase is critical for the formation of reactive oxygen species (ROS) in phagocytic leukocytes and other nonphagocytic cells. NADPH oxidase reduces molecular oxygen to form superoxide anion in a two-step process. Electrons are initially transferred from NADPH to cytochrome b-associated FAD, then to cytochrome b heme and finally to molecular oxygen. We show here that Rac is required for both electron-transfer reactions. Mutational and biophysical analysis shows that Rac and p67phox independently regulate cytochrome b to catalyze the transfer of electrons from NADPH to FAD. However, they must interact with each other to induce the subsequent transfer of electrons from FAD to cytochrome b heme and molecular oxygen. This two-step model of regulation by Rac GTPase may provide a means of more effectively controlling the inflammatory responses of phagocytic leukocytes.

In vitro validation of a new approach for quantitating regurgitations using proximal isovelocity surface area.

The present work has been designed to validate the calculation of the effective regurgitant orifice (ERO) area with the use of a new formula that takes into account the velocity profile (V(r) vs r) and that is insensitive to errors in the determination of the position of the orifice. Assuming a hemispheric model, ERO = 2 pi r(2). V(r)/V(o) (with V(o) = velocity at the orifice) and (V(o)/V(r))(0.5) = (2 pi/ERO)(0.5) r. Thus, the slope of the corresponding linear regression allows ERO to be calculated as: ERO = 2 pi/slope(2). This approach was tested in vitro in pulsatile conditions on circular, conical, and slit-like orifices. The calculated ERO was compared with the actual jet cross sectional area derived from the transverse velocity profile at the jet origin. For the purpose of comparison, the "classical" ERO was calculated for all the configurations, angulations, and threshold velocities. The relationship between (V(o)/V(r))(0.5) was linear (r > 0.98) over a wide range of velocities. The nonhemispheric components were found to modify the constant and not the slope. The mean variation of the calculated ERO was 6.5%. The correlation between the calculated and the actual ERO was very close (>0.97) with slope equal to 0.96. By comparison with the new method, the classical formula gave an underestimation of the ERO that dramatically increased when studying the flow closer to the orifice or in the case of error on the measurement of r. In conclusion, a method using velocity profiles instead of isolated values improves the accuracy of the proximal isovelocity surface area (PISA) method for measuring the ERO.

[Alterations of left ventricular mechanics after anterior myocardial infarction. Quantitative analysis by tissue doppler echocardiography]. / Altérations de la mécanique ventriculaire gauche après infarctus du myocarde antérieur. Etude quantitative par échocardiographie doppler tissulaire.

Myocardial ischemia is usually responsible for alterations of regional left ventricular function which are not quantified by routine echocardiography. We used tissue Doppler echocardiography to quantitate the three main components (radial, longitudinal and angular) of left ventricular function, and their alterations after acute anterior myocardial infarction. Radial function was assessed by the myocardial velocity gradient derived from M-mode color tissue Doppler echocardiography, and longitudinal function by the pulsed wave tissue Doppler echocardiography, in 26 patients who experienced a first acute anterior myocardial infarction and in 11 matched healthy subjects. We describe a new tissue Doppler method for the measurement of septal angular deformation during cardiac contraction. In healthy subjects, our results showed heterogeneous regional myocardial contraction. Septal angular deformation occurred in the same direction and was of the same order as predicted by previous MRI studies. After anterior infarction, systolic and diastolic myocardial velocity gradients were dramatically decreased in the anterior wall when compared with controls (p < 0.01), whereas the systolic velocity gradient was significantly higher in the opposite wall (p < 0.05). Pulsed wave tissue Doppler echocardiography revealed significant alterations of longitudinal left ventricular function. Septal angular deformation was decreased after anterior infarct, and a good correlation was found between the angle of rotation and the left ventricular ejection fraction by cineangiography. These results indicate that tissue Doppler echocardiography has the potential for measuring the three main components of regional left ventricular function, and for quantitatively assessing their functional alterations induced by acute myocardial ischemia.