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.

Three-dimensional computed tomography angiography of the pulmonary veins and their anatomical variations: involvement in video-assisted thoracoscopic surgery-lobectomy for lung cancer.

BACKGROUND: Identification and section of pulmonary veins are an essential part of anatomical pulmonary resections. Intraoperative misunderstandings of pulmonary venous anatomy can lead to serious complications such as bleeding and delayed lung infarction or necrosis. We evaluated principally the rate of pulmonary veno-us anatomical variations, and secondarily the reliability and clinical outcomes of a preoperative morphological analysis. MATERIALS AND METHODS: Between November 2012 and October 2013, we studied 100 consecutive patients with highly suspected or diagnosed stage I-II primitive lung cancer lesion. The surgical procedure initially retained was video-assisted thoracoscopic surgery (VATS) pulmonary resections and we studied preoperatively the proximal pulmonary venous anatomy using 64 channels multi- -detector computed tomography (CT)-scan angiography to describe the venous anatomical variations. RESULTS: There were 65 men and 35 women with a mean age of 63 years. A pulmonary venous anatomical variation was present in 36 (36%) patients, and right-sided anatomical variations were more frequent than on left-sided ones (25% vs. 11%). The most frequent variation encountered on the right side was the existence of three separate pulmonary veins (16%), and on the left side a single pulmonary vein (8%). Surgical conversion occurred in 21% and we didn't experience a pulmonary venous lesion (0%) or a post-operative lung infarction (0%). CONCLUSIONS: We described pulmonary venous anatomical variations and their frequency. Anatomical variations exist and preoperative assessment of pulmo-nary venous anatomy using CT scan is a useful tool in VATS lobectomy to avoid unnecessary extension of pulmonary resections or iatrogenic complications in lung cancer surgery.

[Outpatient thoracic surgery: Evolution of the indications, current applications and limits]. / Chirurgie thoracique ambulatoire : évolution des indications, applications actuelles et limites.

The objectives of outpatient surgery are to reduce the risks connected to hospitalization, to improve postoperative recovery and to decrease the health costs. Few studies have been performed in the field of thoracic surgery and there remains great scope for progress in outpatient lung surgery. The purpose of this article is to present a revue of the current situation and the prospects for the development of out patient thoracic surgery.

A role for CD4+ and CD8+ cells and not for CD25+ cells in the control of Plasmodium berghei Anka blood stage parasites in rats.

In previous studies of the infection of rats by P. berghei Anka, we have shown that primary blood stage infection induced the expansion of CD4+ T cells and CD8+ T cells in adult resistant rats while the number of CD4+CD25+ cells was found to be higher in young susceptible rats. In this work, the respective contribution of each cell population was determined in young and adult rats treated with monoclonal antibodies. Down-regulation of surface CD25 molecules, including those expressed by CD4+ cells did not significantly enhance the capacity of young rats to control the development of erythrocytic stages or modify the course of infection in adult infected rats. However, we observed a significant loss of protection when adult rats were treated with anti-CD4 mAb (W3/25) with higher blood parasitemia levels and approximately 50% of rats succumbed to infection. More importantly and in contrast to earlier studies performed in mice, we found a significant increase in blood parasite levels and a significant delay in parasite clearance in adult rats treated with anti-CD8 mAb OX8, known to deplete CD8+ cells. These results suggest that CD8+ cells play a critical role in the development of immune responses in rats to control the replication of blood stage parasites.

Optimization of patent foramen ovale detection by contrast transthoracic echocardiography using second harmonic imaging.

BACKGROUND: Patent foramen ovale is an anomaly responsible for paradoxical embolizations and cerebral ischemic events. Aims. - We want to show second harmonic transthoracic echography sensitized by contrast agent perfusion is as well as transesophageal echography to patent foramen ovale detection. METHODS: Onene hundred twenty one patients referred for transesophageal echocardiography for patent foramen ovale detection, underwent additive second harmonic transthoracic echocardiography with one of three randomized contrast agents: a mixture A of dextrose and air, mixture B of dextrose and air and blood, or mixture C of hydroxyethylamidon. The severity of atrial shunting was evaluated on recordings by semi-quantitative scoring. Intensity of contrast was also assessed by objective quantitative videodensitometry. RESULTS: No difference was observed between the two techniques, nor between mixture A, B and C in terms of PFO detection during each exam. However, quantitative contrast analysis showed higher intensity with mixtures B and C with mixture A during transthoracic echography. CONCLUSIONS: When performed with a contrast agent, second harmonic transthoracic echography and transoesophageal echography are comparable when it comes to patent foramen ovale detection. Although the composition of the contrast agent does not appear to affect the rate of this detection, contrast quality in the right atrium during transthoracic exam is better with mixtures B and C than with mixture A.

Automated function imaging: a new operator-independent strain method for assessing left ventricular function.

BACKGROUND: Speckle tracking is a new technique based on pure 2D grayscale ultrasound acquisition allowing calculation of segmental strains. To facilitate clinical application, speckle tracking has been integrated into the most recent echocardiographic systems for quick, automated evaluation of left ventricular function (Automated Function Imaging, AFI). OBJECTIVE: To evaluate the feasibility, calculation time, accuracy and reproducibility of global longitudinal strain (GLS) from AFI in determining LV function in comparison to reference echocardiographic and angiographic methods-whatever the operator's experience. METHODS: Echocardiography was performed in 65 patients scheduled for cardiac catheterization using a Vivid 7 system. They were divided into 3 groups according to EF (>55%, 35< or =EF< or =55%,<35%). Image quality, global LV function parameters (ejection fraction, aortic flow, dp/dt) and segmental contraction were analyzed by one experienced operator and one beginner. GLS was obtained from apical 2, 3 and 4 chamber views. GLS was compared to both echocardiographic and angiographic EF, as well as to other echocardiographic parameters. RESULTS: GLS was obtained successfully in 97% of patients. Mean calculation time including correction of endocardial detection was less than 60 seconds. GLS was significantly different between the 3 groups, respectively -18.1+/-2.5%, -11.5+/-2.1% and -6.0+/-1.2% (p<0.01). Strong correlations were observed between GLS and LV function (r from 0.68 to 0.87) with a high level of reproducibility. No difference was observed between experienced and inexperienced operators. CONCLUSION: AFI is clinically applicable and an effective means of assessing LV function due to its short acquisition time, feasibility and accuracy, whatever the experience of the operator.

[The best of echocardiography in 2006]. / L'essentiel de 2006 en échocardiographie.

In recent years, Doppler echocardiography has undergone significant technological advances, resulting in spectacular improvements in diagnosis and quantification. This review summarises the advances made in 2006 in fields as varied as cardiac resynchronisation, cardiac failure with preserved systolic function, contrast echocardiography, 3D echocardiography and echocardiographic evaluation of valvular heart disease. Despite growing competition, but mostly complementarity with CT scan and MRI, Doppler echocardiography remains the keystone of cardiological rationale based on non-intensive investigations.

[Echocardiography and resynchronization in 2007]. / Echocardiographie et resynchronisation en 2007.

Biventricular resynchronisation is accepted as an effective alternative treatment for patients with refractory dilated cardiomyopathy. Based on the presence of ventricular asynchrony, the objective of this technique is to restore homogenous contraction of the myocardial walls. The electrocardiographic criteria for selecting patients only generates a response rate in the order of 70%. Echocardiography has been suggested as another tool for evaluating asynchrony, but there is much confusion in the application of the different criteria. Here we propose an approach based on an understanding of the complexity of myocardial contraction in order to integrate the different echocardiographic parameters in a logical overall evaluation of asynchrony. However, the role of echography does not end with pre-implantation evaluation alone. The follow up of resynchronised patients can effectively benefit from all the opportunities of functional, morphological and hemodynamic investigation, that ultrasound provides. From confirmation of the efficacy of resynchronisation to optimising the pacemaker, the applications of echographic investigation in this field are widespread.

[Thrombosis of valvular prostheses: the role of medical treatment]. / Thrombose de prothèses valvulaires: place du traitement médical.

Thromboses of valvular prostheses represent a rare but serious complication for mechanical valves, and are sometimes fatal. Obstructive thromboses present an immediate threat to life, while the more common, more insidious, non-obstructive thromboses are essentially manifested by thrombo-embolic events. These thromboses often occur at times of insufficient anticoagulation, especially during the first post-operative year and during treatment breaks for non-cardiac surgery, an increasingly common situation. The therapeutic management of an 'obstructive' thrombosis is above all surgical. However, fibrinolysis represents an effective alternative, although it does present a not insignificant risk of systemic embolism (in the order of 10 to 15%). The main indications for fibrinolysis are thromboses of right heart valves, and for left heart prostheses, patients in a very unstable haemodynamic state, remoteness from a cardiac surgery centre, any surgical contraindications, and cases where a large thrombus has been excluded by trans-oesophageal ultrasound. In cases of contraindications to both surgery and fibrinolysis, treatment with heparin might be proposed, but without any great hopes of completely unblocking the prosthesis. Treatment of a 'non-obstructive' thrombosis is primarily medical: optimising anticoagulation with intravenous heparin, or even the addition of aspirin. When the thrombus is large and mobile, surgery should be envisaged if medical treatment fails.

[Identification of candidates for multisite pacing: results and presumed mechanisms of action after five years experience]. / Identification des patients candidats a la stimulation multisite. Résultats et mécanismes d'action supposés a l'issue d'une expérience monocentrique de 5 ans.

Biventricular resynchronisation is an additional therapeutic option in the management of refractory heart failure, with a functional and haemodynamic benefit as well as an improved morbidity and mortality. However, the rate of non-responsive patients has prompted a re-think about the presumed mechanisms of action for this procedure. This study aims to identify candidates more successfully. Based on five years experience in this centre, our work confirmed a medium and long term clinical benefit with multisite pacing. Nevertheless, there was evidence of a relative discordance between the functional benefit and the haemodynamic impact in terms of ejection fraction achieved with resynchronisation. While QRS narrowing appears to be a predictive factor for a successful procedure, the ECG alone is not sufficient to select 'unsynchronised' candidates. Statistical analysis reveals that before implantation the independent predictive factors to identify non-responsive patients include the presence of a complication of myocardial infarction and a low grade mitral leak. The limits of the ECG suggest a more mechanical than electrical approach to understanding the mechanisms of action for resynchronisation. Its effectiveness in cases of right bundle branch block confirm the hypothesis of left intra-ventricular conduction defects, not apparent on the surface ECG but accessible through new imaging techniques. Based on the hypothesis of delayed movement of the ventricular walls, the principle of resynchronisation aims to restore homogenous contraction. Echocardiography allows observation of electromechanical delay and opens new perspectives in the future for selecting patients for pacing. Ar

[Myocardial perfusion and contrast echocardiography. Application to acute coronary syndrome]. / Perfusion myocardique et échocardiographie de contraste. Application au syndrome coronaire aigu.

After mastering epicardial revascularisation, the therapeutic management of acute coronary syndrome has progressively turned towards the preservation of the capillary microcirculation. In this respect, contrast echocardiography provides all the answers to the main questions which arise, and is available within a timeframe and place compatible with the management of such patients. The techniques for microbubble detection, quantification tools, and contrast agents are well optimised for routine use both for initial diagnosis as well as monitoring the therapeutic effectiveness. It is only the administrative authorisation which is currently lacking treatment.

[Diagnosis difficulty in occult constrictive pericarditis]. / Difficulté diagnostique de la péricardite constrictive occulte. A propos d'un cas.

We report the case of a 42 years woman known to have a cardiac heart failure attributed to restrictive cardiomyopathy for want of any other plausible diagnosis. Evolution and repeted investigations finally permitted to rectify the diagnosis by revealing a constrictive pericarditis, remained occult 9 years during. The differentiation of restrictive cardiomyopathy and constrictive pericarditis has been a perennial problem in clinical cardiology. Diagnosis of constrictive pericarditis is based on associated signs sometimes too poor to go straight to thoracotomy. We discuss the mean to approach more precisely this uncommon pattern named occult constrictive pericarditis.

[Echocardiography and biventricular resynchronisation]. / Echocardiographie et resynchronisation biventriculaire.

Biventricular resynchronisation has been recently shown to be an effective therapeutic option in patients with refractory dilated cardiomyopathy. Based on the finding of ventricular asynchrony, the aim of the method is to restore uniform contraction of the ventricular walls. However, the initial electrocardiographic criteria for selection of patients were only associated with a 70% rate of response. Consequently, it became necessary to refocus this method in patients with true ventricular asynchrony. Echocardiography is one of the non-invasive techniques which provides morphological and functional analysis of the myocardium with a high degree of accessibility. The multiplication of tools for echocardiographic quantification has been very valuable from a theoretical point of view for assessing ventricular asynchrony. In practice, techniques such as Doppler tissue imaging are being validated, but already offer the possibility of a multi-directional approach to this pathology. The diagnosis of asynchrony is based on a range of echocardiographic findings which not only improve the selection of patients but also optimise the programming of multisite stimulation.

[Asynchronism and right ventricular pacing]. / Asynchronisme et stimulation ventriculaire droite. Démonstration de l'effet délétère d'une stimulation apicale dans une population d'adultes appareillés pour BAV congénital.

UNLABELLED: In patients with congenital heart block (CHB), dual-chamber pacing restores physiological heart rate and atrio-ventricular synchronization. However, patients with narrow QRS junctional escape rhythm may be deleteriously affected by long-term, permanent, apical ventricular pacing. We assessed the impact of apical ventricular pacing on echocardiographic ventricular dyssynchrony and hemodynamic parameters. METHODS: Fourteen CHB adults (23 +/- years, 58% male), with a DDD transvenous pacemaker and a junctional escape rhythm (QRS<120 ms) before implantation, were studied. Echocardiography coupled with tissue Doppler imaging (TDI) and Strain rate was performed in spontaneous rhythm (VVI mode 30/mn) and during atrio-synchronized ventricular pacing. RESULTS: The heart rate (43 +/- 09 vs 68 +/- 07: p<0.01), cardiac output (2.9 +/- 0.7 vs 3.7 +/- 0.6 L/min) and left ventricular filling time (325 +/- 38 vs 412 +/- 51 ms; p<0.01) were significantly less in the escape spontaneous rhythm compared with atrio-ventricular synchronized apical pacing. However, interventricular dyssynchrony (28 +/- 12 vs 59 +/- 25 ms, p<0.05), intra-left ventricular dyssynchrony (36 +/- 11 vs 57 +/- 29 ms; p<0.05), extent of left ventricular myocardium displaying delayed longitudinal contraction (26 +/- 10 vs 39 +/- 17%: p<0.05) were significantly less in the escape rhythm compared with paced rhythm. CONCLUSION: Once implanted with a DDD pacemaker, CHB patients present with increased cardiac output secondary to the restoration of physiological heart rate and improved diastolic function. However, the apical site is not optimal, as it creates detrimental ventricular dyssynchrony in patients with previous nearly physiological ventricular activation. Alternative pacing sites should be investigated.

["Optigo" hand-held echocardiography in post-surgery of coronary artery bypass graft]. / Intérêt de l'échocardiographe portatif Optigo en période postopérative de chirurgie coronarienne.

INTRODUCTION: After all the advances in electronic miniaturization, first hand-held echocardiographs have finally appeared in echocardiographic laboratories. However, questions still remain about their usefulness in our everyday practice and also about their good diagnosis accuracy. Since some of them do not offer modes such as pulsed or continuous wave Doppler, nor M-mode, they cannot compete with conventional devices. However, they do offer advantages such as their long autonomy, the good quality of their image as well as the one obtained with colour-Doppler mode, in addition obviously to the fact that they can be carried around very easily. OBJECTIVES: To better define their possible uses, we assessed capabilities of one of them, the Optigo (Philips Ultrasound) to analyse patients who had undergone coronary artery bypass surgery. METHOD: Fifty patients have been included in this study few days after the surgery. Each of the patients had two echocardiographic examinations, one with a conventional device and one with the Optigo. Two separated and blinded observers for a subsequent and side-by-side criteria comparison performed the two echocardiograms. RESULTS: Hand-held echocardiography had a good diagnosis accuracy varying from 85% to 95% depending on the analysed criteria. It was more specifically good in the analysis of global or regional left heart function and of the right cavities as well as detecting the existence of pericardial effusion. CONCLUSION: Hand-held echocardiographic device demonstrated high accuracy in assessing patients with recent coronary bypass surgery especially regarding cardiac function and pericardial effusion diagnosis.

Interventricular and intra-left ventricular electromechanical delays in right ventricular paced patients with heart failure: implications for upgrading to biventricular stimulation.

OBJECTIVE: To correlate, in patients with right ventricular pacing (RVP), the QRS width with electromechanical variables assessed by pulsed Doppler tissue imaging echocardiography. Secondly, to find reliable parameters for selecting RVP patients who would respond to biventricular pacing (BVP). METHODS: 26 randomly selected control patients with RVP (mean (SD) ejection fraction 74 (3)%) (group A) were matched on sex and age criteria with 16 RVP patients with drug resistant heart failure (mean (SD) ejection fraction 27 (5)%) (group B). All patients were pacemaker dependent and all underwent pulsed Doppler tissue imaging echocardiography. This technique provided the intra-left ventricular (LV) electromechanical delay and the interventricular electromechanical delay. The Gaussian curve properties of data from group A patients provided the normal range of ECG and echographic parameters. DESIGN: Prospective study. SETTING: University hospital (tertiary referral centre). RESULTS: Data from the control group showed that an interventricular electromechanical delay or an intra-LV electromechanical delay > 50 ms would identify patients with a significantly abnormal ventricular mechanical asynchrony (p < 0.05). In the same manner, a QRS width > 190 ms was considered significantly larger in group B patients (p < 0.05) than in controls. In Group B patients, there was no correlation between the QRS width and the interventricular electromechanical delay (r = -0.23, NS) or the intra-LV electromechanical delay (r = 0.19, NS). Seven group B patients (44%) were misclassified by ECG criteria for ventricular mechanical asynchrony identification: four patients (25%) had a QRS width similar to that of controls but with a significantly prolonged intra-LV electromechanical delay and interventricular electromechanical delay; and three patients (19%) had a QRS width significantly larger than that in controls but without significant ventricular mechanical asynchrony. CONCLUSIONS: The QRS width is not a reliable tool to identify RVP patients with ventricular mechanical asynchrony. In RVP patients, an interventricular electromechanical delay or intra-LV electromechanical delay > 50 ms reflects a significant ventricular mechanical asynchrony and should be required to select patients for upgrading to BVP.

[Cardiac manifestations of amyloidosis by deposits of transthyretin and apolipoprotein A1. Report of 3 families]. / Manifestations cardiaques de l'amylose par dépôts de transthyrétine et d'apolipoprotéine A1. A propos de 3 cas familiaux.

Amyloidosis is characterised by extracellular deposits of a heterogenous protein. Compared with secondary forms, hereditary amyloidosis due to genetic mutations is rare. The authors report the cardiac manifestations in a French family of 5 sisters and 1 brother, three of whom presented with amyloidosis with deposits of transthyretin and apolipoprotein A1 due to a new genetic mutation.

[Contrast echocardiography: from experimental validation to practice]. / Echocardiographie de contraste: de la validation expérimentale à la pratique.

After a long wait, contrast echocardiography is at last becoming a reality. The experimental validation step has been passed with success and the first clinical results bring confirmation. The second generation contrast agents which are arriving on the market, and the spread of enhancement techniques such as Real-Time mode allow perfect visualisation of microbubbles within the left ventricular cavity, but equally at the level of the myocardial crown, thus targeting two direct applications in echocardiography: the first, indisputably, concerns the improvement in the detection of the endocardium in all the situations where it is insufficient, and in particular during stress echography; the second, more ambitious, confronts the study of myocardial perfusion, with a yet to be defined place in clinical practice.

[Contrast echocardiography: from experimental validation into practice]. / Validation et applications de l'échographie de contraste en cardiologie.

Contrast echocardiography is at last becoming a reality. The experimental validation step has been completed with success and the first clinical results bring confirmation. The second generation contrast agents which are becoming available on the market, and the spread of enhancement techniques as Real-time mode allow perfect visualization of microbubbles within the left ventricular cavity, but equally at the level of the myocardial crown, thus targeting two direct applications in echocardiography: the first, indisputably, concerns improvement in the detection of the endocardium in all situations where it is insufficient, and in particular during stress echocardiography; second, more ambitious, is with regards to the study of myocardial perfusion with a potential role in clinical practice that remains to be determined.