Remote management in patients with heart failure (from new onset to advanced): A practical guide.

Heart failure is a chronic condition that affects millions of people worldwide and is associated with high morbidity and mortality. Remote monitoring, which includes the use of non-invasive connected devices, cardiac implantable electronic devices and haemodynamic monitoring systems, has the potential to improve outcomes for patients with heart failure. Despite the conceptual and clinical advantages, there are still limitations in the widespread use of these technologies. Moreover, a significant proportion of studies evaluating the benefit of remote monitoring in heart failure have focused on the limited area of prevention of rehospitalization after an episode of acute heart failure. A group of experts in the fields of heart failure and digital health worked on this topic in order to provide a practical paper for the use of remote monitoring in clinical practice at the different stages of the heart failure syndrome: (1) discovery of heart failure; (2) acute decompensation of chronic heart failure; (3) heart failure in stable period; and (4) advanced heart failure. A careful and critical analysis of the available literature was performed with the aim of providing caregivers with some recommendations on when and how to use remote monitoring in these different situations, specifying which variables are essential, optional or useless.

Stereotactic Radioablation for Ventricular Tachycardia in the Setting of Electrical Storm.

BACKGROUND: Stereotactic body radiotherapy (SBRT) has been reported as a safe and efficient therapy for treating refractory ventricular tachycardia (VT) despite optimal medical treatment and catheter ablation. However, data on the use of SBRT in patients with electrical storm (ES) is lacking. The aim of this study was to assess the clinical outcomes associated with SBRT in the context of ES. METHODS: This retrospective study included patients who underwent SBRT in the context of ES from March 2020 to March 2021 in one tertiary center (CHU Lille). The target volume was delineated according to a predefined workflow. The efficacy was assessed with the following end points: sustained VT recurrence, VT reduced with antitachycardia pacing, and implantable cardioverter defibrillator shock. RESULTS: Seventeen patients underwent SBRT to treat refractory VT in the context of ES (mean 67±12.8 age, 59% presenting ischemic heart disease, mean left ventricular ejection fraction: 33.7± 9.7%). Five patients presented with ES related to incessant VT. Among these 5 patients, the time to effectiveness ranged from 1 to 7 weeks after SBRT. In the 12 remaining patients, VT recurrences occurred in 7 patients during the first 6 weeks following SBRT. After a median 12.5 (10.5-17.8) months follow-up, a significant reduction of the VT burden was observed beyond 6 weeks (-91% [95% CI, 78-103]), P<0.0001). The incidence of implantable cardioverter defibrillator shock and antitachycardia pacing was 36% at 1 year. CONCLUSIONS: SBRT is associated with a significant reduction of the VT burden in the event of an ES; however, prospective randomized control trials are needed. In patients without incessant VT, recurrences are observed in half of patients during the first 6 weeks. VT tolerance and implantable cardioverter defibrillator programming adjustments should be integrated as part of an action plan defined before SBRT for each patient.

High liver fibrosis scores in metabolic dysfunction-associated fatty liver disease patients are associated with adverse atrial remodeling and atrial fibrillation recurrence following catheter ablation.

Background: A number of epidemiological studies have suggested an association between metabolic dysfunction-associated fatty liver disease (MAFLD) and the incidence of atrial fibrillation (AF). However, the pathogenesis leading to AF in the context of MAFLD remains unclear. We therefore aimed at assessing the impact of MAFLD and liver fibrosis status on left atrium (LA) structure and function. Methods: Patients with a Fatty Liver Index (FLI) >60 and the presence of metabolic comorbidities were classified as MAFLD+. In MAFLD+ patients, liver fibrosis severity was defined using the non-alcoholic fatty liver disease (NAFLD) Fibrosis Score (NFS), as follows: MAFLD w/o fibrosis (NFS ≦ -1.455), MAFLD w/indeterminate fibrosis (-1.455 < NFS < 0.675), and MAFLD w/fibrosis (NFS ≧ 0.675). In the first cohort of patients undergoing AF ablation, the structural and functional impact on LA of MAFLD was assessed by LA strain analysis and endocardial voltage mapping. Histopathological assessment of atrial fibrosis was performed in the second cohort of patients undergoing cardiac surgery. Finally, the impact of MAFLD on AF recurrence following catheter ablation was assessed. Results: In the AF ablation cohort (NoMAFLD n = 123; MAFLD w/o fibrosis n = 37; MAFLD indeterm. fibrosis n = 75; MAFLD w/severe fibrosis n = 10), MAFLD patients with high risk of F3-F4 liver fibrosis presented more LA low-voltage areas as compared to patients without MAFLD (16.5 [10.25; 28] vs 5.0 [1; 11] low-voltage areas p = 0.0115), impaired LA reservoir function assessed by peak left atrial longitudinal strain (19.7% ± 8% vs 8.9% ± 0.89% p = 0.0268), and increased LA volume (52.9 ± 11.7 vs 43.5 ± 18.0 ml/m2 p = 0.0168). Accordingly, among the MAFLD patients, those with a high risk of F3-F4 liver fibrosis presented a higher rate of AF recurrence during follow-up (p = 0.0179). In the cardiac surgery cohort (NoMAFLD n = 12; MAFLD w/o fibrosis n = 5; MAFLD w/fibrosis n = 3), an increase in histopathological atrial fibrosis was observed in MAFLD patients with a high risk of F3-F4 liver fibrosis (p = 0.0206 vs NoMAFLD; p = 0.0595 vs MAFLD w/o fibrosis). Conclusion: In conclusion, we found that liver fibrosis scoring in MAFLD patients is associated with adverse atrial remodeling and AF recurrences following catheter ablation. The impact of the management of MAFLD on LA remodeling and AF ablation outcomes should be assessed in dedicated studies.

Incidence and predictors of mortality after an electrical storm in the ICU.

AIMS: For assessing predictors of early mortality following hospitalization for electrical storm (ES), only limited data are available. The purpose of this study was to assess the incidence and predictors of early mortality following hospitalization in the intensive care unit (ICU) for ES in a large retrospective study. METHODS AND RESULTS: In this retrospective study, we included all patients who were hospitalized for ES from July 2015 to May 2020 in our tertiary centre. A total of 253 patients were included. The median age was 66 [56; 73], and 64% had ischemic cardiomyopathy. A total of 37% of patients presented hemodynamic instability requiring catecholamine at admission. A total of 17% of patients presented an acute reversible cause for ES. The one-year mortality was 34% (95% CI, 30-43%), mostly driven by heart failure (HF). The multivariable Cox's regression model identified age, left ventricular ejection fraction, right ventricle dysfunction, haemoglobin level as independent predictors of one-year mortality. The use of catecholamine at admission was identified as the only variable related to the initial management of ES associated with an increased 30-day mortality risk (HR: 7.95 (95%CI, 3.18-19.85). CONCLUSION: In patients admitted for ES in ICU, the one-year mortality remains high and mostly driven by HF. The use of catecholamine at admission is associated with a seven-fold risk for mortality within 30 days. In such patients, the potential use of VT ablation can be questioned and a careful action plan regarding invasive HF-related therapy could be considered.

Intraoperative cone beam computed tomography to improve outcomes after infrarenal endovascular aortic repair.

OBJECTIVE: We evaluated whether a combination of intraoperative contrast-enhanced cone beam computed tomography (ceCBCT) and postoperative contrast-enhanced ultrasound (CEUS) after infrarenal endovascular abdominal aortic aneurysm repair (EVAR) could reduce late stent graft-related complications and, consequently, reintervention. METHODS: All consecutive patients who had received infrarenal bifurcated stent grafts in our hybrid room (IGS 730; GE Healthcare, Île-de-France, France) during two discrete periods were included in the present study. From November 2012 to September 2013, two-dimensional completion angiography was performed after each EVAR, followed by computed tomography angiography (CTA) before discharge (group 1). From October 2013 to January 2015, intraoperative ceCBCT was performed, followed by CEUS within the first postoperative days (group 2). Comparative analyses of the outcomes were performed. The primary endpoint was late stent graft-related complications, a composite factor incorporating aneurysm-related death, type I or III endoleaks, kink or occlusion of the iliac limb, and aortic sac enlargement after the first 30 postoperative days. The secondary endpoint was all stent graft-related reinterventions. All-cause and aneurysm-related deaths were also recorded. RESULTS: Overall, 100 consecutive patients (50 each in groups 1 and 2) were enrolled, with a median follow-up of 60 months (interquartile range, 41-69 months). At 60 months after the index procedure, the freedom from late stent graft-related complications in each group was 61.6% (95% confidence interval [CI], 47.0%-80.6%) for group 1 and 81.7% (95% CI, 70.1%-95.2%) for group 2 (P = .033). The use of intraoperative ceCBCT was independently associated with a reduced rate of late stent graft-related complications on multivariate analysis (hazard ratio, 0.39; 95% CI, 0.16-0.95; P = .038) but did not appear to significantly protect against stent graft-related reinterventions (hazard ratio, 0.53; 95% CI, 0.20-1.39; P = .198) or all-cause death (P = .47). CONCLUSIONS: To the best of our knowledge, the present study is the first to report the influence of routine ceCBCT on late outcomes after EVAR. The use of ceCBCT shows the potential for reducing late stent graft-related complications associated.

Usefulness of remote monitoring for the early detection of back-up mode in implantable cardioverter defibrillators.

BACKGROUND: Reversion of an implantable cardioverter defibrillator (ICD) to back-up mode degrades the operating capabilities of the device, puts patients at risk and requires rapid intervention by a manufacturer's technician. AIM: To illustrate the usefulness of remote monitoring of ICDs for the early detection of reversion to back-up mode. METHODS: In our centre, all patients implanted with an ICD, with or without resynchronisation, were offered remote monitoring as soon as the technology became available. Alerts triggered by the remote monitoring system were included prospectively in a register. During a mean follow-up of 5.7±1.3 years, a total of 1594 patients with an ICD (441 with resynchronisation function) followed with remote monitoring were included in the register. RESULTS: Among 15,874 alerts, only 10 were related to a reversion to back-up mode. Among those, seven reversions were caused by radiotherapy, two were fake events and one was caused by magnetic resonance imaging. Except for the two fake events, the eight other patients had an emergency admission for the resetting and reprogramming of their ICD. None of the reversion to back-up mode alerts was followed by a clinical alert (i.e. a shock alert) before the ICD problem was resolved. CONCLUSIONS: Reversion to back-up mode is a very rare event, accounting for 0.06% of total alerts; remote monitoring facilitates the early detection of this critical event to resolve the problem faster than the next scheduled follow-up. Remote monitoring can prevent serious damage to the patient and avoids systematic ambulatory control of the ICD after each radiotherapy session.

No impact of sports practice before or after atrial fibrillation ablation on procedure efficacy in athletes: a case-control study.

AIMS: Limited data exist on the efficacy of catheter ablation (CA) for sport-related atrial fibrillation (AF). Impact of sports practice resumption post-CA remains unknown. We aimed to determine AF CA efficacy in athletes vs. non-athletes, and to assess the impact of sport practice resumption. METHODS AND RESULTS: From 1153 first-time AF CA performed between 2009 and 2017, 73 athletes were matched with 73 sedentary patients based on age, sex, and closest CA procedure date. Athletes were defined as performing ≥6 h/week of vigorous sports to achieve ≥2000 h accumulated lifetime sports activity. They were mostly males (93.2%) with a mean age of 55 ± 9.8 years. Before CA, athletes practiced 10.2 ± 3.9 h/week of vigorous exercise vs. 4.6 ± 3.4 after CA. Within first year after CA, physical activity was stopped in 12 (16.4%) athletes, lowered in 45 (61.9%), and resumed at same intensity in 16 (21.9%). Athletes and non-athletes suffered from same AF recurrence rates during 5-year follow-up after CA: 38 (52.0%) vs. 35 (47.9%), respectively [adjusted hazard ratio (HR) on age, body mass index (BMI), obstructive sleep apnoea (OSA), and reduced left ventricular ejection fraction (LVEF), 1.17 (0.70-1.97, P = 0.54)]. No significant impact of physical activity resumption status was found regarding AF recurrence rates at 1-year and beyond (P = 0.60). Procedure effectiveness was significantly lower in athletes with non-paroxysmal AF [adjusted on age, BMI, reduced LVEF, and OSA HR 2.36 (confidence interval 1.19-4.70), P = 0.01]. CONCLUSION: Sports practice before and after CA has no significant impact on AF recurrence rates in athletes within 5-year after AF CA.

A report on the impact of remote monitoring in patients with S-ICD: Insights from a prospective registry.

INTRODUCTION: Several clinical studies have demonstrated that remote monitoring (RM) offers potential benefits in transvenous implantable cardioverter defibrillator (ICD). The potential interest of RM in subcutaneous-ICD (S-ICD) recipients has never been evaluated. The aim of this study was to evaluate the alert burden and its clinical relevance in a prospective cohort of S-ICD recipients. METHODS: We prospectively and consecutively enrolled all patients undergoing S-ICD implantation at Lille University Hospital from September 2015 to January 2017 and gave them a LATITUDE™ NXT RM system. The relevance of transmissions was assessed by the following ratio: number of transmissions leading to reaction or intervention per patient/number of transmissions per patient. RESULTS: From September 2015 to January 2017, 69 patients were enrolled with a mean follow-up of 415 ± 96.3 days. The mean age was 44.6 ± 15.6 years old, and 25% (n = 17) had ischemic cardiomyopathy. At the end of follow-up, 12% of the patients had events recorded by RM. These events were related to nine ICD shocks and eight untreated events. A total of 1,423 transmissions were collected. Most of these transmissions were patient-initiated without any event (77%, n = 1,096) or scheduled without any event (19%, n = 272). Only 3.2% ± 1.1 of the transmissions per patient led to reactions or interventions. CONCLUSION: On the basis of the current method of transmitting, S-ICD RM allowed detection of relevant events in 12% of patients but generated a high unactionable transmission burden. As a result of these findings, efforts should be made to optimize transmissions considering automatic transmissions and to focus on patient education.

Epicardial fat amount is associated with the magnitude of left ventricular remodeling in aortic stenosis.

Both genetic and environmental factors interact to control left ventricular (LV) remodeling in the context of aortic stenosis (AS). Epicardial adipose tissue (EAT) is a specific visceral adipose tissue with paracrine properties in close contact with the myocardium. We sought to assess determinants of EAT amount and its association with the magnitude and pattern of LV remodeling in patients suffering from severe AS. Between January 2014 and September 2017, we prospectively explored consecutive patients referred to our Heart Valve Center for SAVR presenting with severe AS and normal left ventricular ejection fraction (> 50%). Comprehensive transthoracic echocardiography (TTE) including assessment of LV remodeling and EAT amount were performed. 202 patients were included. EAT was significantly larger in elderly, diabetic and obese patients. EAT thickness was correlated positively with indexed LV mass in AS (r2 = 0.21; p < 0.0001) as well as severe LV remodeling pattern. Importantly, this observation persisted after adjustment for other factors associated with LV remodeling (ß ± SE = 1.74 ± 0.34; p < 0.0001). Large amounts of EAT are positively and independently associated with more pronounced and severe LV remodeling in severe AS. Further exploration regarding the impact of functional properties of EAT on LV remodeling is required.

Recommendations for the use of electrophysiological study: Update 2018.

The field of cardiac electrophysiology has greatly developed during the past decades. Consequently, the use of electrophysiological studies (EPSs) in clinical practice has also significantly augmented, with a progressively increasing number of certified electrophysiology centers and specialists. Since Zipes et al published the Guidelines for Clinical Intracardiac Electrophysiology and Catheter Ablation Procedures in 1995, no official document summarizing current EPS indications has been published. The current paper focuses on summarizing all relevant data of the role of EPS in patients with different types of cardiac pathologies and provides up-to-date recommendations on this topic. For this purpose, the PubMed database was screened for relevant articles in English up to December 2018 and ESC and ACC/AHA Clinical Practice Guidelines, and EHRA/HRS/APHRS position statements related to the current topic were analyzed. Current recommendations for the use of EPS in clinical practice are discussed and presented in 17 distinct cardiac pathologies. A short rationale, evidence, and indications are provided for each cardiac disease/group of diseases. In conclusion, because of its capability to establish a diagnosis in patients with a variety of cardiac pathologies, the EPS remains a useful tool in the evaluation of patients with cardiac arrhythmias and conduction disorders and is capable of establishing indications for cardiac device implantation and guide catheter ablation procedures.

Left atrial epicardial adipose tissue radiodensity is associated with electrophysiological properties of atrial myocardium in patients with atrial fibrillation.

OBJECTIVE: To evaluate whether the epicardial adipose tissue (EAT) phenotype is associated with the electrophysiological properties of adjacent atrial myocardium in patients with atrial fibrillation (AF). METHODS: Between January and May 2017, 30 consecutive patients referred for a first AF catheter ablation were prospectively included. For each patient, a pre-procedural computed tomography scan was performed to assess total and left atrial (LA) EAT amount and radiodensity. A detailed point-by-point voltage mapping using an electroanatomic mapping system was realized to assess the presence of LA low-voltage zone (LVZ). RESULTS: Ten patients (33.3%) presented at least one LVZ. Older age (65 ± 7 vs. 58 ± 10 years, p = 0.05) was the only clinical parameter associated with LVZ. Despite no greater LA-EAT thickness by CT scan (3.0 [2.6-3.5] mm vs. 2.8 [2.2-3.1] mm, p = 0.354), patients with LA-LVZ presented significantly lower LA-EAT radiodensity than patients with no LA-LVZ (- 101.8 ± 12.5 HU vs. - 90.4 ± 6.3 HU, p = 0.004). No difference between total-EAT volume (131 ± 61 cm3 vs.107 ± 58 cm3, p = 0.361) and total-EAT radiodensity (- 106.8 ± 4.3 HU vs. - 102.4 ± 6.9 HU, p = 0.119) was found. CONCLUSION: Low LA-EAT radiodensity is associated with the presence of LVZ in patients with medical history of AF. KEY POINTS: • Cardiovascular risk factors are associated with low adipose tissue computed tomography attenuation. • Epicardial adipose tissue (EAT) has emerged as an important factor in the pathogenesis of metabolic-related cardiac diseases such as atrial fibrillation. • We showed that low left atrial EAT attenuation is associated with the presence of low-voltage zone, a surrogate for atrial fibrosis, within the adjacent myocardium.

Daytime variation of perioperative myocardial injury in cardiac surgery and its prevention by Rev-Erbα antagonism: a single-centre propensity-matched cohort study and a randomised study.

BACKGROUND: On-pump cardiac surgery provokes a predictable perioperative myocardial ischaemia-reperfusion injury which is associated with poor clinical outcomes. We determined the occurrence of time-of-the-day variation in perioperative myocardial injury in patients undergoing aortic valve replacement and its molecular mechanisms. METHODS: We studied the incidence of major adverse cardiac events in a prospective observational single-centre cohort study of patients with severe aortic stenosis and preserved left ventricular ejection fraction (>50%) who were referred to our cardiovascular surgery department at Lille University Hospital (Lille, France) for aortic valve replacement and underwent surgery in the morning or afternoon. Patients were matched into pairs by propensity score. We also did a randomised study, in which we evaluated perioperative myocardial injury and myocardial samples of patients randomly assigned (1:1) via permuted block randomisation (block size of eight) to undergo isolated aortic valve replacement surgery either in the morning or afternoon. We also evaluated human and rodent myocardium in ex-vivo hypoxia-reoxygenation models and did a transcriptomic analysis in myocardial samples from the randomised patients to identify the signalling pathway(s) involved. The primary objective of the study was to assess whether myocardial tolerance of ischaemia-reperfusion differed depending on the timing of aortic valve replacement surgery (morning vs afternoon), as measured by the occurrence of major adverse cardiovascular events (cardiovascular death, myocardial infarction, and admission to hospital for acute heart failure). The randomised study is registered with ClinicalTrials.gov, number NCT02812901. FINDINGS: In the cohort study (n=596 patients in matched pairs who underwent either morning surgery [n=298] or afternoon surgery [n=298]), during the 500 days following aortic valve replacement, the incidence of major adverse cardiac events was lower in the afternoon surgery group than in the morning group: hazard ratio 0·50 (95% CI 0·32-0·77; p=0·0021). In the randomised study, 88 patients were randomly assigned to undergo surgery in the morning (n=44) or afternoon (n=44); perioperative myocardial injury assessed with the geometric mean of perioperative cardiac troponin T release was significantly lower in the afternoon group than in the morning group (estimated ratio of geometric means for afternoon to morning of 0·79 [95% CI 0·68-0·93; p=0·0045]). Ex-vivo analysis of human myocardium revealed an intrinsic morning-afternoon variation in hypoxia-reoxygenation tolerance, concomitant with transcriptional alterations in circadian gene expression with the nuclear receptor Rev-Erbα being highest in the morning. In a mouse Langendorff model of hypoxia-reoxygenation myocardial injury, Rev-Erbα gene deletion or antagonist treatment reduced injury at the time of sleep-to-wake transition, through an increase in the expression of the ischaemia-reperfusion injury modulator CDKN1a/p21. INTERPRETATION: Perioperative myocardial injury is transcriptionally orchestrated by the circadian clock in patients undergoing aortic valve replacement, and Rev-Erbα antagonism seems to be a pharmacological strategy for cardioprotection. Afternoon surgery might provide perioperative myocardial protection and lead to improved patient outcomes compared with morning surgery. FUNDING: Fondation de France, Fédération Française de Cardiologie, EU-FP7-Eurhythdia, Agence Nationale pour la Recherche ANR-10-LABX-46, and CPER-Centre Transdisciplinaire de Recherche sur la Longévité.

Arrhythmogenic right ventricular cardiomyopathy and left atrial tachycardia: a case report.

Little is known about atrial arrhythmias in arrhythmogenic right ventricular cardiomyopathy (ARVC). A 46-year-old man with definite ARVC presented with palpitations and exertional dyspnoea. Electrocardiogram showed a supraventricular tachycardia. Despite no prior cardiac surgery or atrial fibrillation ablation, electrophysiological study revealed a left atrial (LA) re-entrant circuit characterized by a slow fractionated potential bounded by two areas of double potentials giving a figure-of-eight pattern on activation map. Located on the LA roof within a zone of low bipolar voltages, this unusual substrate can be associated with a primitive atrial myopathy in ARVC.

Design and synthesis of a novel anchoring ligand for highly efficient thin film dye-sensitized solar cells.

A novel ligand, 5,5'-(2,2'-bipyridine-4,4'-diyl)-bis(thiophene-2-carboxylic acid) (BTC), and its Ru(II) complex (BTC-1) in which the anchoring group is attached to the thiophene units were developed. Using a low-volatility electrolyte and 3.3 mum mesoporous TiO2 films BTC-1 achieved a solar-to-electricity conversion efficiency of 6.1%, compared to 4.8% for N719 under the same experimental conditions.

White-light phosphorescence emission from a single molecule: application to OLED.

A simple mononuclear cyclometallated iridium(iii) complex exhibits white photo- and electro- luminescence in the wavelength range from 440 to 800 nm, which originates from a single emitting excited state of mixed character.