[Ischemia : when the ECG do not tell us everything]. / Ischémie : quand l'ECG ne nous dit pas tout.

The electrocardiogram recording, when an acute coronary syndrome is suspected, is of paramount importance as the modifications of the ST segment confirms the diagnosis of STEMI (ST-elevation myocardial infarction) which needs immediate treatment, or NSTEMI (Non-ST elevation myocardial infarction). In case of NSTEMI, the invasive procedure is generally performed in the first 24 to 72 hours. However, one patient in four present an acute occluded artery at the time of the coronary angiography and this is associated with a worse outcome. In this article, we describe an emblematic case, discuss the worse outcome of these patients and explore some ways to prevent this problem.

La réalisation de l'ECG lors de suspicion d'un syndrome coronarien aigu (SCA) occupe une place primordiale. En effet, c'est sur la présence ou l'absence d'un sus-décalage du segment ST que le diagnostic d'infarctus aigu type STEMI (infarctus myocardique avec élévation du segment ST), avec nécessité d'une prise en charge immédiate, ou NSTEMI (infarctus myocardique sans élévation du segment ST), est posé. En cas d'infarctus NSTEMI, en règle générale, la coronarographie est effectuée dans les 24 à 72 heures. Toutefois, 1 patient sur 4 avec infarctus NSTEMI présente une occlusion artérielle aiguë au moment de la coronarographie. Cela est associé à un mauvais pronostic au long cours. Dans cet article, nous vous présentons un cas illustratif et une synthèse de la littérature sur le mauvais pronostic de ces patients et quelques pistes afin d'éviter ce problème.

[Takotsubo syndrome in a peripheral hospital: not always typical]. / Syndrome de Takotsubo à l'hôpital: pas toujours typique.

In this paper, we describe the clinical presentation of 2 patients with atypical Takotsubo syndrome recently observed in our hospital. It is the occasion de review the clinical characteristics, the biological markers, the imaging clues as well as the diagnosis criteria, the treatment algorithm and the prognostic of this disease, first described 30 years ago by our Japanese colleagues. The current knowledge of this recently summarized entity in an international expert consensus document is the main reference of this presentation.

Dans cet article, nous décrivons 2 cas de présentation atypique d'un syndrome de Takotsubo survenus récemment à l'hôpital de Morges. C'est l'occasion de revoir le tableau clinique, la démarche diagnostique, les caractéristiques biologiques et d'imagerie, le traitement et le pronostic de cette affection décrite pour la première fois il y a 30 ans par nos collègues japonais. Nous nous sommes basés en particulier sur un document de consensus d'experts internationaux qui rassemblent toutes les connaissances actuelles sur cette affection.

[Cardiology]. / Cardiologie.

In 2019, the guidelines on the new entity « chronic coronary syndrome ¼ have been published. They influence importantly the work-up and treatment of patients with stable coronary artery disease. We will also report on publications showing the benefit of percutaneous aortic valve implantation (TAVI) in patients with aortic stenosis and low risk surgical risk. With regard to infectious endocarditis, we elucidate the importance of the vegetation's size for predicting mortality and the prognostic value of the positron emission tomography in predicting septic embolism. We highlight the spectacular results of the DAPA-HF study in patients with heart failure and review publications showing the important role of the detection of myocardial fibrosis and scar by cardiac MRI for risk stratification of sudden cardiac death.

L'année 2019 a été marquée par la publication de recommandations sur une nouvelle entité, appelée « syndrome coronarien chronique ¼, qui modifient de manière importante la prise en charge et le traitement des patients avec une maladie coronarienne stable. On relève plusieurs publications démontrant, chez les patients ayant une sténose aortique, et étant à bas risque chirurgical, le bénéfice d'un traitement percutané par rapport à un traitement chirurgical. La prise en charge de l'endocardite a été challengée par deux publications montrant que la taille de la végétation est un facteur de risque de mortalité et la valeur pronostique de la tomographie par émission de positons dans la survenue d'emboles septiques. Nous discutons les résultats spectaculaires de l'étude DAPA-HF dans le domaine d'insuffisance cardiaque et plusieurs études montrant l'intérêt de la recherche de cicatrice myocardique à l'IRM cardiaque dans la stratification du risque de mort subite.

[The year in cardiology : 2018]. / Cardiologie.

This review article provides a broad overview of the novelties in cardiology in 2018. Advances in interventional cardiology and cardiovascular prevention, heart failure, electrophysiology and non-invasive cardiovascular imaging have provided important new insights in the pathophysiology, diagnosis and treatment of ischemic and valvular heart disease, heart failure, rhythm disorders and cardiomyopathies. This article provides an overview of the most relevant articles published in 2018.

L'année 2018 a été riche en nouveautés dans les domaines de la cardiologie interventionnelle, de l'insuffisance cardiaque, de l'électrophysiologie et de l'imagerie cardiaque. Les progrès dans ces domaines respectifs ont fourni de nouveaux outils pour le diagnostic et le traitement des cardiopathies ischémiques et valvulaires, de l'insuffisance cardiaque à fraction d'éjection réduite ou préservée, des troubles du rythme et des cardiomyopathies. Cet article fournit un aperçu des articles les plus pertinents publiés en 2018.

[Therapeutic options in advanced heart failure : place of durable left ventricular assist device (LVAD)]. / Options thérapeutiquesdans l'insuffisance cardiaque avancée : place de l'assistance ventriculaire gauche permanente (LVAD).

Despite the benefit of the drugs acting on neuro-humoral activation and cardiac resynchronization therapy, some patients will end in a severe refractory form of heart failure: advanced heart failure. The only therapeutic options with a positive impact on mortality and quality of life are heart transplantation and permanent left ventricular assist device (LVAD). The significant technological improvements of the past 20 years lead to a reduction of the complications associated with these devices, which now allow their use not only during the waiting period preceding heart transplantation (bridge to transplant), but also as a durable therapeutic option (destination therapy).

Malgré le bénéfice des médicaments agissant sur l'activation neuro-humorale et de la thérapie de resynchronisation, certains patients vont évoluer vers une forme sévère et réfractaire d'insuffisance cardiaque : l'insuffisance cardiaque avancée (ICA). Les seules options thérapeutiques de l'ICA ayant démontré un impact favorable sur la survie et la qualité de vie sont la transplantation cardiaque et l'implantation d'un dispositif d'assistance ventriculaire gauche permanent (LVAD, Left Ventricular Assist Device). Les importantes améliorations technologiques des vingt dernières années ont permis de réduire significativement les complications associées à ces dispositifs, permettant non seulement leur utilisation dans l'attente du greffe cardiaque (bridge to transplant), mais aussi comme option thérapeutique définitive (destination therapy).

Decongestion improving right heart function ameliorates prognosis after an acute heart failure episode.

BACKGROUND: The prognostic role of decongestion-related change of cardiac morphology and in particular right heart function has not been investigated comprehensively in AHF patients. METHODS AND RESULTS: This prospective observational single-centre study included consecutive patients hospitalized for treatment of AHF with reduced, mildly-reduced or preserved left ventricular ejection fraction (LVEF). Comprehensive transthoracic echocardiography at admission and discharge assessed decongestion-related change of cardiac function and morphology. The combined endpoint of 1 year all-cause mortality and cardiovascular rehospitalization explored the prognostic importance of decongestion-related change. The 176 study participants were 83 years old [74-87] and 54% were men. Fifty one (29%) had rLVEF, 65 (37%) mrLVEF, and 60 (34%) pLVEF. The proportion of de novo or worsening chronic HF was not different between LVEF groups. HF aetiology and cardiovascular risk factors were equally distributed across all groups except for a higher BMI in the pLVEF group. Decongestion equally reduced body weight, heart rate, systolic and diastolic blood pressure, tricuspid regurgitation gradient, and inferior vena cava diameter across all groups (P < 0.004 for all). Decongestion-related increase in TAPSE independent of the LVEF was associated with improvement of right-ventricular-pulmonary artery coupling and a lower incidence of the combined outcome in the Cox proportional hazard risk analysis (unadjusted HR 0.50 95% CI 0.33-0.78, P = 0.002; adjusted HR 0.46 95% CI: 0.33-0.78, P = 0.001). CONCLUSIONS: Decongestion-related increase in TAPSE and recovery of RV/pulmonary artery coupling was observed across all LVEF groups and associated with a risk reduction for the combined endpoint highlighting the important prognostic role of right heart recovery after an AHF episode.

A role for the Reitan catheter pump for percutaneous cardiac circulatory support of patients presenting acute congestive heart failure with low output and renal dysfunction?

Outcomes in acute decompensated heart failure remain poor, in particular when patients present with impaired renal function. Recent results indicate that treatment of acute decompensated heart failure patients with the Reitan catheter pump not only increases cardiac index, but also improves renal function resulting in maintained increase of diuresis. These favorable effects were achieved without significant hemolysis, bleeding or vascular complications suggesting that Reitan catheter pump treatment has the potential to facilitate recovery from acute decompensated heart failure with low output and complicated by renal dysfunction.

Non-severe aortic regurgitation increases short-term mortality in acute heart failure with preserved ejection fraction.

AIMS: Mild or moderate aortic regurgitation (AR) has only little effect on cardiovascular outcome in people with normal left ventricular ejection fraction (EF); therefore, it is not perceived as a major clinical problem. This study investigates whether mild or moderate AR is associated with increased short-term mortality in patients hospitalized for treatment of acute heart failure (AHF) and whether mild or moderate AR impacts differently on short-term mortality in AHF patients with reduced EF (AHFrEF), mid-range EF (AHFmrEF), or preserved EF (AHFpEF). METHODS AND RESULTS: This mono-centric study included 505 consecutive adult patients hospitalized for de novo or worsening chronic HF not related to acute ischaemia or severe valvular pathology in the echocardiogram at index hospitalization. Cox regression analysis studied the impact of AR on all-cause mortality (ACM) over the 150 days' study period. Mild or moderate AR was associated with increased ACM (HR 1.75 [95% CI: 1.1-2.7]; P = 0.009). The prevalence of mild or moderate AR in the study population was 42% and not significantly different between AHFpEF (n = 227), AHFmrEF (n = 86), and AHFrEF (n = 192) study participants (37.9% vs. 50.0% vs. 42.7%; P = 0.144). In AHFpEF patients, the age-adjusted hazard for ACM was increased in patients with AR compared with patients without AR (HR 2.17 [95% CI: 1.1-4.2]; P = 0.002). The age-adjusted hazard for ACM was increased by a trend in AHFmrEF with AR (HR 7.11, [95% CI: 0.9-57.8]; P = 0.067) and not different between the AHFrEF groups (HR 0.95 [95% CI: 0.5-1.8]; P = 0.875). CONCLUSIONS: Mild or moderate AR increased ACM only in AHFpEF patients, highlighting a distinct clinical relevance.

Short-term single-centre experience with the HeartMate 3 left ventricular assist device for advanced heart failure.

OBJECTIVES: The objective of this study was to analyse clinical characteristics, survival and adverse events of patients with advanced heart failure supported using the Abbott HeartMate 3 left ventricular assist device (LVAD). METHODS: We retrospectively reviewed 42 consecutive HeartMate 3 recipients implanted in our centre between 1 November 2015 and 31 October 2019. RESULTS: Our series comprised 39 males, aged 56.7 ± 11.8 years. Eleven (26%) patients had preimplant INTERMACS clinical profiles of 1 or 2. The mean duration support was 14.0 ± 10.6 months (range 0.69-44 months). During follow-up, 4 (10%) patients died while on support, 13 (35%) patients received a heart transplant and 25 patients are still ongoing. Actuarial survival after LVAD implantation was 88.4 ± 5.5% and 84.4 ± 6.6% at 1 and 2 years, respectively. There were no cases of pump thrombosis or technical malfunction. Seven (17%) patients required post-implant temporary right ventricular support. Adverse events included bleeding requiring surgery in 13 (31%) patients, gastrointestinal bleeding in 6 (14%) patients, LVAD-specific infections in 19 (45%) patients and non-disabling ischaemic stroke in 5 (12%) patients. The incidence of ischaemic stroke was significantly higher in patients where the outflow graft was anastomosed to the descending aorta as compared to those where it was anastomosed to the ascending aorta (P < 0.003). CONCLUSIONS: We have observed satisfactory survival rates using the HeartMate 3 LVAD for long-term mechanical circulatory support. The absence of technical failure, pump thrombosis, haemolysis or need for pump exchange during our 4-year experience confirms its technical reliability and improved haemocompatibility, but bleeding complications and infections remain a concern.