Focus on malignant ventricular premature contractions.

Premature ventricular contractions (PVCs) are common. Although often benign, they can also be associated with increased morbidity and mortality. The aim of this review was to assess the risk evaluation of PVCs in patients with or without structural heart disease and discuss the management of this arrhythmia. Reports published in English were searched in PubMed with the following search terms: premature ventricular contraction, ectopic ventricular beat, ventricular extrasystole, antiarrhythmic drugs, ablation, ventricular arrhythmia, ventricular tachycardia, ventricular fibrillation and torsade de pointe. This analysis suggests that all patients with frequent PVCs should be assessed for PVC burden, symptom status and the presence of structural heart disease. PVCs in patients with structurally normal hearts was once considered a benign phenomenon. Uncommonly, PVCs may provoke life-threatening arrhythmias. Ventricular fibrillation is the initial mode of malignant rapid ventricular arrhythmias (MRVAs). Patients with malignant PVC and PVC burden >10% are at increased risk of MRVA in case of myocardial infarction and heart failure. MRVA is the primary cause of sudden cardiac death in patients with and without structural heart disease. Therapeutic options include medical therapy and catheter ablation, the latter more effective and potentially curable, particularly in patients with left ventricular dysfunction. The timely recognition and effective treatment of malignant PVCs in symptomatic patients with underling cardiomyopathy are mandatory to initiate early therapies before the occurrence of adverse clinical outcomes and to improve the long-term prognosis.

[Association of hypertension and antihypertensive agents and the severity of COVID-19 pneumonia. A monocentric French prospective study]. / Association entre l'hypertension artérielle, les traitements inhibiteurs du système rénine angiotensine et les formes graves de COVID-19. Étude prospective monocentrique française.

BACKGROUND AND AIM: Angiotensin converting enzyme (ACE) type 2 is the receptor of SARSCoV-2 for cell entry into lung cells. Because ACE-2 may be modulated by ACE inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), there are concern that patients treated with ACEIs and ARBs are at higher risk for COVID-19 infection or severity. This study sought to analyse the association of severe forms of COVID-19 and mortality with hypertension and a previous treatment with ACEI and ARB. METHODS: Prospective follow-up of 433 consecutive patients hospitalised for COVID-19 pneumonia confirmed by PCR or highly probable on clinical, biological, and radiological findings, and included in the COVHYP study. Mortality and severe COVID-19 (criteria: death, intensive care unit, or hospitalisation >30 days) were compared in patients receiving or not ACEIs and ARBs. Follow-up was 100% at hospital discharge, and 96.5% at >1month. RESULTS: Age was 63.6±18.7 years, and 40%) were female. At follow-up (mean 78±50 days), 136 (31%) patients had severity criteria (death, 64 ; intensive care unit, 73; hospital stay >30 days, 49). Hypertension (55.1% vs 36.7%, P<0.001) and antihypertensive treatment were associated with severe COVID-19 and mortality. The association between ACEI/ARB treatment and COVID-19 severity criteria found in univariate analysis (Odds Ratio 1.74, 95%CI [1.14-2.64], P=0.01) was not confirmed when adjusted on age, gender, and hypertension (adjusted OR1.13 [0.59-2.15], P=0.72). Diabetes and hypothyroidism were associated with severe COVID-19, whereas history of asthma was not. CONCLUSION: This study suggests that previous treatment with ACEI and ARB is not associated with hospital mortality, 1- and 2-month mortality, and severity criteria in patients hospitalised for COVID-19. No protective effect of ACEIs and ARBs on severe pneumonia related to COVID-19 was demonstrated.

[Isolated right ventricular acute myocardial infarction mimicking anterior infarction]. / Infarctus isolé du ventricule droit mimant un infarctus antérieur.

Isolated right ventricular acute myocardial infarction is rare and its presentation can sometimes mimic an anterior ST-segment elevation myocardial infarction. We reported two cases of isolated right ventricular acute myocardial infarction presenting with a ST-elevation in anterior leads. The first case was admitted for an out-of-hospital cardiac arrest due to ventricular fibrillation. The patient died from neurologic consequences of the cardiac arrest, despite a successful prehospital thrombolysis, followed by a percutaneous angioplasty of the right coronary artery. The second case occurred after a complex percutaneous angioplasty of the right coronary artery, complicated by a total occlusion of a right marginal branch. These two cases illustrate the limits of the ECG for the diagnosis of isolated right ventricular acute infarction, and the difficulties of the differential diagnosis with anterior infarction, which may determine the treatment and the prognosis.

[Coronary artery spasm revealed by an out-of-hospital cardiac arrest associated with a moyamoya disease. A case report of multimodality imaging]. / Arrêt cardiaque par spasme coronaire associé à une maladie de Moyamoya. Apport de l'imagerie cardiaque multimodale.

Moyamoya disease is a rare angiopathy characterized by a progressive distal occlusion of the internal carotid arteries and their branches. Extracerebral involvement, including coronary arteries, has been described. We report the case of a patient with moyamoya disease who suffered an out-of-hospital cardiac arrest associated with coronary spasm. We discussed the possible links between coronary spasm and moyamoya, as well as the contribution of multimodal cardiac imaging, combining conventional and intracoronary imaging, cardiac MRI, provocative tests for spasm, in the exploration of out-of-hospital cardiac arrest without obvious electrocardiographic and angiographic cause.

Immediate coronary angiography in survivors of out-of-hospital cardiac arrest without obvious extracardiac cause: Who benefits?

BACKGROUND: Immediate coronary angiography (iCA) and primary percutaneous coronary angioplasty (pPCI) in patients successfully resuscitated after out-of-hospital cardiac arrest (OHCA) of suspected cardiac cause is controversial. Our aims were to assess the results of iCA, the prognostic impact of pPCI after OHCA, and to identify subgroups most likely to benefit from this strategy. METHODS: In this single-centre retrospective study, patients aged ≥18 years with sustained return of spontaneous circulation after OHCA and no evidence of a non-cardiac cause underwent routine iCA at admission, with pPCI if indicated. Results of iCA, and factors associated with in-hospital survival were analysed. RESULTS: Between 2006 and 2013, 160 survivors from OHCA presumed of cardiac origin were included (median age, 60 years; 85% males). iCA showed significant coronary-artery lesions in 75% of patients, and acute occlusion or unstable lesion in only 41%. pPCI was performed in 34% of patients and was not associated with survival by univariate or multivariate analysis (P=0.67). ST-segment elevation predicted acute coronary occlusion in 40%. An initial shockable rhythm was associated with higher in-hospital survival (52% vs. 19%; P<0.001). After initial defibrillation, the first rhythm recorded by 12-lead electrocardiography was highly associated with prognosis: secondary asystole had a very low survival rate (5%, 1/21) despite PCI in 43% of patients, compared to sustained ventricular tachycardia/fibrillation (42%, 15/36) and supraventricular rhythm (71%, 50/70) (P<0.001). CONCLUSIONS: In our experience, the prevalence of acute coronary occlusion or unstable lesion immediately after OHCA of likely cardiac cause is only 41%. Immediate CA in OHCA survivors, with pPCI if indicated, should be restricted to highly selected patients.

[Complicated transcatheter aortic-valve endocarditis with abscess and pseudoaneurysm: Value of the ECG-gated multidetector computed tomography angiography]. / Endocardite infectieuse sur TAVI compliqué d'abcès et pseudo-anévrysme : apport du scanner cardiaque synchronisé à l'ECG.

A 80-year-old man was admitted to catheterization room for an acute infero-lateral ST-elevation myocardial infarction (STEMI). Coronary angiography showed a thrombotic occlusion of the second left marginal branch, and normal other coronary arteries. The thrombo-embolic mechanism of the STEMI, and the infectious context in this patient who had had a transcatheter aortic valve implantation (TAVI) two months earlier, led us to suspect a bioprosthesis endocarditis. It was confirmed by transthoracic and transoesophageal echocardiography, which showed an aortic-mitral curtain abscess and aortic bioprosthesis vegetations, associated to Enterococcus faecalis bacteriemia. In order to specify the diagnosis, an ECG-gated multidetector CT angiography (MDCTA) had been performed. Additionally to echocardiographic findings, MDCTA showed a pseudo-aneurysm, sized 20 to 22mm, beginning from the outflow tract of the left ventricle to end on the antero-lateral face of the aorta. The patient was referred for emergency aortic bioprosthesis removal and replacement. Through this case, MDCTA showed its importance for the diagnosis and the prognostic evaluation of cardiac prosthesis endocarditis. MDCTA provided additional informations that echocardiography could not detect, because of artifacts caused by the prosthetic material and calcifications, frequent in elderly patients with comorbidities.

Assessment of global longitudinal strain at low-dose anthracycline-based chemotherapy for the prediction of subsequent cardiotoxicity.

OBJECTIVES: The aim of this study was to assess whether global longitudinal strain (GLS) measured early during treatment with anthracycline (at a cumulative dose of 150mg/m2) can predict subsequent alterations in left ventricular ejection fraction (LVEF). METHODS AND RESULTS: Eighty-six patients suffering from Hodgkin's disease, non-Hodgkin's lymphoma or acute leukemia and receiving anthracyclines were prospectively included. They underwent complete echocardiography on four separate occasions: baseline (V1); after reaching a cumulative dose of 150mg/m2 (V2); end of treatment (V3); one year follow-up (V4). Six patients developed cardiotoxicity defined by a decrease in LVEF by more than 10 percentage points to a value of at least less than 53% at V4. Both GLS measured at V1 and at V2 were significantly lower in the cardiotoxicity group compared with the control group (P=0.042 and P=0.01, respectively). Compared to GLS at V1, GLS obtained at V2 provided implemental predictive information and appeared to be the strongest predictor of cardiotoxicity (area under the receiver operating characteristic curve, 0.823). At a threshold of -17.45% for GLS measured at V2, the sensitivity and specificity of detecting cardiotoxicity were 67% (95%CI: [33-100%]) and 97% (95%CI: [94-100%]) respectively. CONCLUSION: GLS>-17.45%, obtained after 150mg/m2 of anthracycline therapy, is a significant predictor of future anthracycline-induced cardiotoxicity. This study should encourage physicians to perform echocardiography earlier during treatment with anthracyclines.

[Intracoronary administration of antithrombotic agents via a perfusion balloon catheter in patients with ST-segment elevation myocardial infarction presenting with massive intraluminal thrombus and failed aspiration]. / Apport de l'administration intracoronaire d'antithrombotiques par cathéter à ballon de perfusion en phase aiguë d'infarctus du myocarde avec thrombus massif et échec de la thromboaspiration.

BACKGROUND: Massive intracoronary thrombus is associated with adverse procedural results including failed aspiration and unfavourable reperfusion. We aim to evaluate the effect of the intracoronary administration of antithrombotic agents via a perfusion catheter in patients with ST-segment elevation myocardial infarction (STEMI) presenting with a large thrombus burden and failed aspiration. METHODS: We retrospectively analyzed the thrombus burden, the TIMI grade flow, and the myocardial Blush in 25 consecutive STEMI patients with a large thrombus burden and failed manual aspiration, who received intracoronary infusion of glycoprotein IIb/IIIa inhibitors (N=17) or bivalirudine (N=8) via a 6F-infusion catheter (ClearWay™ RX) RESULTS: Mean age was 67±14 years, 16 patients (64 %) presented with anterior STEMI, and 7 (28 %) with cardiogenic shock. Immediately after intracoronary infusion, the TIMI flow grade improved of 2 grades in 7 patients (28 %), and 1 grade in 14 (56 %), a complete resolution of the thrombus was observed in 9 patients, and a >50 % resolution in 12. Blush was improved of 3 grades in 15 patients (60 %), of 2 grades in 7 (28 %), and Blush grade 0 remained in 3. At the end of procedure, we observed normal TIMI 3flow in most patients (92 %), a complete resolution of thrombus in 80 %, and a Blush grade 3 in 68 %. CONCLUSIONS: In STEMI patients presenting with a large thrombus burden and failed aspiration, intracoronary administration of glycoprotein IIb/IIIa inhibitors or bivalirudin via the perfusion catheter ClearWay™ RX significantly reduced the thrombus burden and improved the TIMI flow and the Blush grade, without bleeding.

[Coronary stent evaluation with cardiac CT: Literature review]. / Évaluation des stents coronaires en scanner cardiaque: revue de la littérature.

Since the introduction of the 64-generation scanners, the accuracy and robustness of the diagnosis of coronary artery disease has progressed. The main advantage of cardiac CT is the exclusion of coronary artery disease by its excellent negative predictive value. Currently, cardiac CT applications extend thanks to innovations both in terms of technological development systems scanner or stents implanted. This is a literature review of stent evaluation with cardiac CT.

[Evolution of the interventional reperfusion strategy and reperfusion times in acute ST-segment elevation myocardial infarction]. / Évolution de la prise en charge interventionnelle et des délais de reperfusion à la phase aiguë de l'infarctus du myocarde avec sus-décalage du segment ST.

BACKGROUND: In patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), the recommended times (first medical contact-to-balloon (M2B) <120 or <90min, and door-to-balloon (D2B) <45min) are reached in less than 50% of patients. PURPOSE: To compare the interventional reperfusion strategy and reperfusion times between two series of consecutive STEMI patients referred for pPCI within 12hours of symptom onset, in 2007 and 2012. METHODS: Retrospective study of 182 patients, 87 admitted from January 2007 to March 2008 (period 1), and 95 admitted from January to December 2012 (period 2). The procedural characteristics and the different times between onset of pain and mechanical reperfusion were gathered and compared by non-parametric tests. RESULTS: Radial access, thromboaspiration, and drug eluting stents were more frequent, and cardiogenic shock was less common during period 2, compared with the period 1. The median time from first medical contact to balloon (M2B) decreased by 26% (135min, [quartiles: 113-183] in 2007 versus 100 [76-137] in 2012, P<0.001), in relation to the reduction in both prehospital times and time in the catheterization laboratory (D2B: 51 [44-65] and 44min [37-55], respectively, P<0.01). CONCLUSIONS: The D2B and M2B times significantly decreased in our centre between 2007 and 2012, and reached the recommended values in >60% of the cases. This may be explained by better coordination between emergency medical units and interventional cardiologists, and by the presence of two paramedics in the catheterization laboratory for 24/24 7/7 pPCI since 2010 in France, in accordance with recent national regulation.

[Usefulness of transesophageal echocardiography to optimize treatment after ischemic stroke]. / Intérêt de l'échocardiographie trans-œsophagienne dans l'optimisation de la stratégie thérapeutique après un accident vasculaire cérébral ischémique.

AIM OF THE STUDY: In the setting of ischemic stroke, the place of transesophageal echocardiography (TEE) is still matter of debate. The aim of the study is to evaluate the therapeutic impact provided by TEE and to characterize patients in whom TEE is warranted. PATIENTS AND METHOD: Three hundred and fifty-nine consecutive patients were included in the study. "Decisive TEE" (DTEE) was defined by echographic findings resulting in a change of treatment, whereas "informative TEE" (ITEE) was defined by TEE revealing a potential cardiac or aortic source of embolism. RESULTS: Three hundred and forty-one patients underwent TEE. Twenty-eight patients (8.2%) had DTEE and 184 (53.9%) had ITEE. DTEE were as follows: thrombus in the left atrial appendage in 6 patients, complex aortic plaques in 10 patients, patent foramen ovale (PFO) associated with atrial septal aneurism (ASA) and an important right to left shunt (3 patients), FOP associated with ASA and lower limb phlebitis (1 patient), 4 cases of endocarditis and 4 patients with intense spontaneous echo contrast in the left atrium. In most cases of DTEE (67.8%), the patient was given anticoagulation drugs. Left atrial dilatation (P=0.005) and multivessel territory stroke (P=0.018) were statistically predictive of DTEE. CONCLUSIONS: In the setting of ischemic stroke, TEE provides important additional informations, but modifies therapeutic strategy in less than 10% of cases. Multivessel territory stroke, and left atrial dilatation were predictive of DTEE.

Assessment of coronary bypass graft patency by first-line multi-detector computed tomography.

The purpose of the study was to assess whether a strategy based on a MDCT performed routinely before CA can reduce the radiation dose during the CA, without increased global exposure in patients who need imaging of CABG. A total of 147 consecutive patients were included. The radiation dose during CA (KAP 12.1 vs 22.0 Gy/cm(2), P<.01) and the volume of iodinated contrast (155 vs 200 mL, P<.02) were reduced when preceded by a MDCT. Patients' cumulative exposures were not different in the 2 strategies (5.0 vs 5.1 mSv, P=.76). MDCT performed in first line is a valuable strategy for the assessment of CABG.

[Undifferentiated sarcoma: usefulness of multimodality cardiac imaging in characterizing a rare intracardiac mass]. / Sarcome cardiaque indifférencié : intérêt de l'imagerie multimodale dans la caractérisation d'une masse intracardiaque.

We report the case of a man presenting with a Pierre Marie-Bamberger syndrome. This paraneoplastic syndrome revealed an undifferentiated intracardiac sarcoma. This case emphasizes the need for multimodality imaging to characterize intracardiac tumor.

[Cardiac MRI: technology, clinical applications, and future directions]. / IRM cardiaque : technologie actuelle, applications cliniques et perspectives futures.

The field of cardiovascular MRI has evolved rapidly over the past decade, feeding new applications across a broad spectrum of clinical and research areas. Advances in magnet hardware technology, and key developments such as segmented k-space acquisitions, advanced motion encoding techniques, ultra-rapid perfusion imaging and delayed myocardial enhancement imaging have all contributed to a revolution in how patients with ischemic and non-ischemic heart disease are diagnosed and treated. Actually, cardiac MRI is a widely accepted method as the "gold standard" for detection and characterization of many forms of cardiac diseases. The aim of this review is to present an overview of cardiac MRI technology, advances in clinical applications, and future directions.

[Use and limitations of invasive coronary strategy in nonagerians]. / Intérêts et limites de la stratégie invasive coronaire chez les patients nonagénaires.

BACKGROUND: Nonagenarians are systematically excluded from studies of interventional cardiology. Few data exist on the usefulness, safety, and results of coronary angiography (CA) and percutaneous coronary intervention (PCI) in this population. PURPOSE: To evaluate the benefits and hazards of CA and PCI in nonagenarians. METHODS: Retrospective study conducted from the database (Cardioreport(®)) of the CH de Versailles, from January 2001 to December 2011. RESULTS: From the 15,806 procedures performed in the center during the period, 107 (0.9%) were done in 97 patients aged ≥90years. Half of them underwent PCI. Median age was 92±2years (range: 90 to 100), 56% were women. Main indication was an acute coronary syndrome (77%, acute STEMI in 39%). The first group (n=58) had a single CA leading to strengthen medical treatment, and CABG in one case. The second group (n=49) had a CA followed by immediate (41) or delayed (8) PCI. The primary success rate of PCI was 90%. Radial route was used in 94% in the period 2009-2011 (51% overall). Failure of arterial access (4%) and difficulties of catheterization (13%) were rare. Severe complications occurred in 19%. They were local (11 hematomas, 6 severe, 4 transfusions, and 1 fatal acute ischemia of a lower limb), and general (1 stroke, 1 death by left main rupture during PCI). Twenty percent of the complications (11% of severe ones) were directly related to the procedure. Overall hospital mortality was 10%. CONCLUSIONS: Angiography is feasible in nonagenarians by radial approach without failures and with a reduced rate of complications. PCI was indicated in about half of the cases. PCI may be proposed in nonagerians with a high success rate, and an acceptable risk of local and general complications.

[Low dose cardiac computed tomography: how to obtain it?]. / Scanner cardiaque basse dose: comment l'obtenir?

Since the introduction of Multi-slice computed tomography (CT), cardiac CT has been the increasingly used as a noninvasive modality for the diagnosis of coronary disease. Despite its potential benefits and promising clinical results, it has suffered from high doses of radiation associated with a risk of radiation-induced cancers. This has raised serious concerns in clinical practice. A number of strategies were then implemented to reduce the radiation dose associated with cardiac CT. The aim of this review is not to compare doses of different CT systems available on the market but to present an overview of different approaches to dose reduction and future directions.

[Diagnostic value of clinical signs and clinical scoring for deep vein thrombosis after hip and knee arthroplasty]. / Dépistage clinique de la thrombose veineuse profonde après prothèse de hanche et de genou. Proposition d'un score de prédiction pour guider l'indication de l'échographie-Doppler veineux.

AIM: To assess the most accurate clinical signs and clinical scoring for selecting patients who could benefit from duplex sonography screening of deep venous thrombosis (DVT) after total hip replacement (THR) and total knee replacement (TKR). METHODS: Four hundred and eighty consecutive patients with THR or TKR were included. Post-operative physical examination and venous duplex sonography (day 6-10) were performed in all of them. DVT was diagnosed in presence of at least 3mm thick and 3 cm long incomplete venous compressibility. Clinical prediction scores were built from clinical parameters, which were significantly associated with DVT in univariate analysis, one of them weighted from logistic multivariate regression coefficients. RESULTS: Recent DVT was diagnosed in 74 patients (15.7%) (29.6% after TKR and 8.4% after THR). There was no isolated proximal DVT and extensive DVTs were very rare (TKR 1.2% vs. THR 1%). Two TKR patients developed pulmonary embolism (1.2%). One died (0.6%). Univariate analysis showed significant association between provoked localized limb pain, pitting edema and difference in calf circumference (DCC), and DVT (P<0.0001). DCC> 3 cm was significantly associated with DVT (32.4% vs. 16.6%, OR 2.4 [1.3-4.2] ; P=0.001). In multivariate analysis the only two clinical manifestations independently associated with DVT were provoked localized limb pain (adjusted OR 2.3 [1.3-4.1] ; P<0.01) and DCC> 3 cm (adjusted OR 2.0 [1.1-3.8] ; P=0.04). A clinical score value greater or equal to 4 was associated with a risk of DVT of 34%, and a value<4 with a risk of 9%. CONCLUSIONS: After THR or TKR, DCC> 3 cm or a clinical risk score greater or equal to 4 could be used as an accurate and easy clinical test for assessing the need for further DVT screening by sonography.