Impact of COVID-19 on the incidence of cardiac arrhythmias in implantable cardioverter defibrillator recipients followed by remote monitoring.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has been a fast-growing worldwide pandemic. AIMS: We aimed to investigate the incidence of cardiac arrhythmias among a large French cohort of implantable cardioverter defibrillator recipients over the first 5 months of 2020. METHODS: Five thousand nine hundred and fifty-four implantable cardioverter defibrillator recipients were followed by remote monitoring during the COVID-19 period (from 01 January to 31 May 2020). Data were obtained from automated remote follow-up of implantable cardioverter defibrillators utilizing the Implicity® platform. For all patients, the type of arrhythmia (atrial fibrillation, ventricular tachycardia or ventricular fibrillation), the number of ventricular arrhythmia episodes and the type of implantable cardioverter defibrillator-delivered therapy were recorded. RESULTS: A total of 472 (7.9%) patients presented 4917 ventricular arrhythmia events. An increase in ventricular arrhythmia incidence was observed after the first COVID-19 case in France, and especially during weeks #10 and #11, at the time of major governmental measures, with an increase in the incidence of antitachycardia pacing delivered therapy. During the 11 weeks before the lockdown order, the curve of the percentage of live-stream television coverage of COVID-19 information matched the ventricular arrhythmia incidence. During the lockdown, the incidence of ventricular arrhythmia decreased significantly compared with baseline (0.05±0.7 vs. 0.09±1.2 episodes per patient per week, respectively; P<0.001). Importantly, no correlation was observed between ventricular arrhythmia incidence and the curve of COVID-19 incidence. No changes were observed regarding atrial fibrillation/atrial tachycardia episodes over time. CONCLUSIONS: An increase in ventricular arrhythmia incidence was observed in the 2 weeks before the lockdown order, at the time of major governmental measures. Ventricular arrhythmia incidence decreased dramatically during the lockdown.

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.

Acquired left ventricular submitral aneurysms in the course of Takayasu arteritis in a child.

A 9-year-old black African boy was hospitalized for heart failure revealing a severe left ventricular dysfunction associated with dilated cardiomyopathy, two submitral aneurysms, occlusion of the circumflex artery and a giant coronary artery aneurysm on the proximal left anterior descending artery. The boy was coinfected with human immunodeficiency virus and Mycobacterium tuberculosis. Though rare, association of Takayasu arteritis and submitral aneurysm leads to rethinking the pathogenesis of submitral aneurysm and suggests that some of them may be acquired. In our case, a common inflammatory process, possibly triggered by tuberculosis or HIV, may underlie Takayasu and submitral aneurysms.

Incidental extracardiac findings in cardiac computed tomography performed before radiofrequency ablation of atrial fibrillation.

BACKGROUND: Radiofrequency ablation has became a validated therapeutic technique for symptomatic drug refractory atrial fibrillation (AF). Cardiac computed tomography (CT) is used to evaluate left atrial (LA) anatomy in order to improve AF ablation. The analysis of noncardiac structures during cardiac CT may identify clinically significant incidental findings (IFs). The objective of this study was to determine the prevalence of IF in patients undergoing AF catheter ablation. METHODS: Between February 2008 and March 2010, all patients planned for a first procedure of AF or LA tachycardia (LAT) ablation underwent a cardiac CT scan and were retrospectively included in this study. Extracardiac IFs were considered to be present if an abnormality was identified without previous clinical suspicion or known disease. RESULTS: Two hundred and fifty patients (55.2 ± 9.6 years of age, 82.4% men) were enrolled (133 paroxysmal, 43 persistent, 58 permanent AF, and 16 LAT). Fifty-eight patients (23.2%) had a total of 76 IFs. Patients with IF were significantly older (59.5 ± 8.2 vs 53.8 ± 9.7 years old, P < 0.001). No relationship existed between the type of arrhythmia and IF existence. The majority of IFs were pulmonary (50%), with 15.8% of pulmonary emphysema. Two cases of lung cancer and of pulmonary fibrosis, 15 mediastinal adenopathies, and three congenital coronary arteries anomalies were found. CONCLUSIONS: Cardiac CT scan is a useful tool to evaluate LA morphology before AF ablation. However, as a considerable prevalence of IF was found in our study, extracardiac structures should be routinely analyzed to detect unknown conditions, which could require specific management.

High-resolution endocardial and epicardial optical mapping in a sheep model of stretch-induced atrial fibrillation.

Atrial fibrillation (AF) is a complex cardiac arrhythmia with high morbidity and mortality.(1,2) It is the most common sustained cardiac rhythm disturbance seen in clinical practice and its prevalence is expected to increase in the coming years.(3) Increased intra-atrial pressure and dilatation have been long recognized to lead to AF,(1,4) which highlights the relevance of using animal models and stretch to study AF dynamics. Understanding the mechanisms underlying AF requires visualization of the cardiac electrical waves with high spatial and temporal resolution. While high-temporal resolution can be achieved by conventional electrical mapping traditionally used in human electrophysiological studies, the small number of intra-atrial electrodes that can be used simultaneously limits the spatial resolution and precludes any detailed tracking of the electrical waves during the arrhythmia. The introduction of optical mapping in the early 90's enabled wide-field characterization of fibrillatory activity together with sub-millimeter spatial resolution in animal models(5,6) and led to the identification of rapidly spinning electrical wave patterns (rotors) as the sources of the fibrillatory activity that may occur in the ventricles or the atria.(7-9) Using combined time- and frequency-domain analyses of optical mapping it is possible to demonstrate discrete sites of high frequency periodic activity during AF, along with frequency gradients between left and right atrium. The region with fastest rotors activates at the highest frequency and drives the overall arrhythmia.(10,11) The waves emanating from such rotor interact with either functional or anatomic obstacles in their path, resulting in the phenomenon of fibrillatory conduction.(12) Mapping the endocardial surface of the posterior left atrium (PLA) allows the tracking of AF wave dynamics in the region with the highest rotor frequency. Importantly, the PLA is the region where intracavitary catheter-based ablative procedures are most successful terminating AF in patients,(13) which underscores the relevance of studying AF dynamics from the interior of the left atrium. Here we describe a sheep model of acute stretch-induced AF, which resembles some of the characteristics of human paroxysmal AF. Epicardial mapping on the left atrium is complemented with endocardial mapping of the PLA using a dual-channel rigid borescope c-mounted to a CCD camera, which represents the most direct approach to visualize the patterns of activation in the most relevant region for AF maintenance.

Coronary angiography of pregnancy-associated coronary artery dissection: a high-risk procedure.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome occurring predominantly in young women without any cardiovascular risk factors, especially during the peripartum and early postpartum period. Here, we report a case of a 28-year-old pregnant woman who was found to have an isolated distal SCAD of the left anterior descending artery (LAD). Coronary angiography was complicated by extensive LAD and circumflex arteries dissection, requiring an emergency coronary artery bypass grafting associated with ventricular assist device implantation and underlying the extreme fragility of coronary arteries in pregnant women.

[Frequency and type of gifts given by pharmaceutical industry to cardiology residents]. / Fréquence et type de cadeaux reçus par les internes de cardiologie de la part de l'industrie pharmaceutique.

OBJECTIVE: Cardiovascular diseases are the leading cause of death in the world and cardiologists are an important target for the pharmaceutical industry. We evaluated cardiology residents' exposure to pharmaceutical companies. METHODS: A survey was sent by e-mail in July 2009 to all residents of the Cardiology and Vascular Diseases program endorsed by the French Society of Cardiology. RESULTS: The questionnaire was completed by 149 (56%) residents. Among them, 145 (97%) had at least one promotional item in their white coat. Non-educational gifts (such as pens and notepads) and scientific papers reprints are the most frequently received gifts. Pharmaceutical companies have invited 117 (79%) residents to a local or national congress and 42 (29%) to an international congress. Most residents consider gifts as ethically appropriate, particularly scientific textbooks, invitations to congresses and educational seminars. Among the 128 residents who assessed the value of a gift likely to compromise a physician's judgment, 36 (28%) answered < 100 euro, 51 (40%) between 101 and 1000 euro and 41 (32%) >1000 euro. CONCLUSIONS: Cardiology residents in France frequently interact with the pharmaceutical industry, receiving not only small gifts but also support to their medical education. Interactions with industry are generally considered appropriate and training on their ethical implications and influence on prescribing could be implemented during residency.

Takotsubo cardiomyopathy associated with Guillain-Barré syndrome: a differential diagnosis from dysautonomia not to be missed.

A 60-year-old woman presented with a 1-week progressive limb weakness and an areflexic tetraparesis. Both neurophysiological and cerebrospinal fluid examinations were consistent with diagnosis of Guillain-Barré syndrome (GBS) and a treatment by intravenous immunoglobulin over a 5-day period was started. At the end of the treatment, the patient suffered from an acute coronary syndrome (ACS) without stenosis at coronary arteriography. Left ventriculography showed segmental wall motion abnormalities with apical akinesis contrasting with hyperkinesis in basal segments, with a depressed left ventricular ejection fraction at 45%. Cardiac magnetic resonance imaging excluded the diagnosis of myocarditis. A diagnosis of "transient left ventricular apical ballooning syndrome" or "Takotsubo" syndrome was then made and a treatment by angiotensin-converting enzyme inhibitor and beta-blocker was introduced. Left ventricular dysfunction and electrocardiogram normalized within two weeks and the patient remained free from cardiovascular events at one year of follow-up. This cardiomyopathy is a recently known and now commonly diagnosed reversible systolic dysfunction mimicking ACS and is secondary to physical or emotional stress affecting mainly post-menopausal women. Electrocardiographic and echocardiographic abnormalities are often regressive in days or weeks, and rarely responsible for complications. This observation supports clinical evidence that electrocardiographic changes in GBS can be linked to Takotsubo syndrome, by means of the stressful trigger of GBS occurrence. This reversible cardiomyopathy needs adequate management and specific therapeutic strategies. Therefore, trans-thoracic echocardiography should be systematically performed when repolarisation abnormalities are present in this disease to rule out a Takotsubo syndrome, even in asymptomatic patients.