Contemporary management of patients with atrial fibrillation in the Netherlands and Belgium: a report from the EORP-AF long-term general registry.

BACKGROUND: Contemporary data regarding the characteristics, treatment and outcomes of patients with atrial fibrillation (AF) are needed. We aimed to assess these data and guideline adherence in the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) long-term general registry. METHODS: We analysed 967 patients from the EORP-AF long-term general registry included in the Netherlands and Belgium from 2013 to 2016. Baseline and 1­year follow-up data were gathered. RESULTS: At baseline, 887 patients (92%) received anticoagulant treatment. In 88 (10%) of these patients, no indication for chronic anticoagulant treatment was present. A rhythm intervention was performed or planned in 52 of these patients, meaning that the remaining 36 (41%) were anticoagulated without indication. Forty patients were not anticoagulated, even though they had an indication for chronic anticoagulation. Additionally, 63 of the 371 patients (17%) treated with a non-vitamin K antagonist oral anticoagulant (NOAC) were incorrectly dosed. In total, 50 patients (5%) were overtreated and 89 patients (9%) were undertreated. However, the occurrence of major adverse cardiac and cerebrovascular events (MACCE) was still low with 4.2% (37 patients). CONCLUSIONS: Overtreatment and undertreatment with anticoagulants are still observable in 14% of this contemporary, West-European AF population. Still, MACCE occurred in only 4% of the patients after 1 year of follow-up.

[Case of refractory cardiogenic shock due to venlafaxine overdose : illustration of the support with veno-arterial extracorporeal membrane oxygenation]. / Choc cardiogénique réfractaire lié à une intoxication volontaire en venlafaxine : illustration de l'intérêt de l'ECMO veino-artérielle.

Venlafaxine is a widely prescribed antidepressant drug acting as a reuptake inhibitor of serotonin and noradrenaline. An overdose of venlafaxine can cause cardiovascular toxicity and cardiogenic shock can occur. A 32-year-old man ingested 12g of sustained-release venlafaxine in a suicidal attempt and developed within 24h acute heart failure with refractory cardiogenic shock requiring support by ECMO. The blood toxicology showed persistence of high levels of venlafaxine at day 10. The patient fully recovered and showed normal cardiac function at 3-months follow-up.

La venlafaxine est un antidépresseur largement prescrit agissant comme inhibiteur de recapture de la sérotonine et de la noradrénaline. Un surdosage en venlafaxine peut engendrer une toxicité cardiovasculaire allant jusqu'à l'état de choc cardiogénique. Un homme de 32 ans a ingéré 12 g de venlafaxine sous une forme à libération prolongée dans une tentative de suicide et a développé en 24 heures une insuffisance cardiaque aiguë avec choc cardiogénique réfractaire nécessitant un support hémodynamique par ECMO. La toxicologie sanguine a montré la persistance de niveaux élevés de venlafaxine au jour 10. Le patient s'est ensuite complètement rétabli et présentait une fonction cardiaque normale 3 mois après l'épisode.

Immune Cells and Immunosenescence.

Aging is associated with progressive loss of physiological integrity, leading to impaired physical and mental functions as well as increased morbidity and mortality. With advancing age, the immune system is no longer able to adequately control autoimmunity, infections, or cancer. The abilities of the elderly to slow down undesirable effects of aging may depend on the genetic background, lifestyle, geographic region, and other presently unknown factors. Although most aspects of the immunity are constantly declining in relation to age, some features are retained, while e.g. the ability to produce high levels of cytokines, response to pathogens by increased inflammation, and imbalanced proteolytic activity are found in the elderly, and might eventually cause harm. In this context, it is important to differentiate between the effect of immunosenescence that is contributing to this decline and adaptations of the immune system that can be quickly reversed if necessary.

[CARDIOVASCULAR INVOLVEMENTS IN BEHÇET'S DISEASE: "ANGIO-BEHÇET"]. / MANIFESTATIONS CARDIOVASCULAIRES DE LA MALADIE DE BEHÇET: "ANGIO-BEHÇET".

Behçet's disease is a relapsing, immune-mediated systemic vasculitis that may affect blood vessels of all types and sizes. Nowadays, the etiology remains unclear. In the absence of a biological marker or pathognomonic radiology, the diagnosis is mainly based on clinical manifestations. The cardiovascular involvement, known as "angio-Behçet", is relatively common and affects up to 40% of patients. It typi- cally occurs in a young male, usually during the onset of the disease. In general, immunosuppressive and anticoagulant therapies initiated early are likely to induce a remarkable cli- nical improvement. Nevertheless, prompt recognition of the polymorphous cardiovascular manifestations of the disease is challenging and may be responsible for some considerable delay prior to initiation of adequate therapy. The aim of this article is to describe the spectrum of cardiovascular involve- ments of Behçet's disease in order to optimize detection and therapeutic management.

[LEFT ATRIAL APPENDAGE CLOSURE IN A PATIENT WITH SYSTEMIC SCLEROSIS]. / LE CAS CLINIQUE DU MOIS. Fermeture percutanée de L'auricule gauche chez une patiente souffrant de sclérodermie.

We report the clinical history of a 69 year-old female who suffered from systemic sclerosis and in whom we performed a percutaneous left atrial appendage closure due to recurrent gastrointestinal bleedings under anticoagulant therapy for chronic atrial fibrillation. We review the impact of scleroderma on the cardiac and digestive systems and discuss the issue of anticoagulation and its alternatives in uncommon clinical situations. We also describe the indications, technical aspects and potential complications of percutaneous left atrial appendage closure.

[A CASE OF FLECAINIDE INTOXICATION]. / Intoxication par flécaïnide. Observation d'un cas et revue de la litérature.

Flecainide acetate is an antiarrhythmic agent commonly used in clinical practice, in particular, for the treatment of supraventricular tachycardias. We report a rare case of voluntary poisoning by flecainide. The patient was successfully resuscitated.A review of the literature related to this type of intoxication is presented.

[Clinical case of the month. Spontaneous hematoma and acquired hemophilia]. / Le cas clinique du mois. Hématomes spontanés et hémophilie acquise.

Acquired haemophilia is a rare disease, 50% of the cases are idiopathic. We report a case admitted in cardiology for spontaneous hematoma. Observation of isolated prolonged activated partial thromboplastin time (aPPT) without anticoagulation treatment and the absence of correction with normal plasma suggested diagnosis. Confirmation of inhibitors to FVIII allowed perfusions of activated prothrombin complex concentrates.

[A left intraventricular mass]. / Le cas clinique du mois. A propos d'une masse intra-ventriculaire gauche.

We report the case of a 29-years-old male presenting with a large mass inserted at the hypokinetic apex of the left ventricle. Without any early regression under anticoagulant therapy and taking into account recent neurological manifestations, surgical extraction was decided. The mass corresponded to a chronic thrombus lying on a non-transmural myocardial necrosis. This case gives us the opportunity to review all causes of intracardiac masses.

Low occurrence of Clostridium difficile in fecal samples of healthy calves and pigs at slaughter and in minced meat in Switzerland.

Clostridium difficile is a cause of diarrhea and colitis in humans. The increase of incidence and severity of C. difficile infections in humans in past years is due, at least in part, to the emergence of more virulent strains (PCR ribotypes 027 and 078). Recent studies describe the occurrence of hypervirulent strains in ground meat products. Therefore, food animals and food need to be assessed for their possible role as vectors of C. difficile to humans. In this pilot study, fecal samples of 204 calves and 165 pigs, as well as 46 minced meat products were investigated to determine the occurrence of C. difficile in farm animals at slaughter and in ground meat products at the retail level in Switzerland. C. difficile was isolated from only one fecal sample of a calf. All samples from pigs and ground meat were negative. Further characterization revealed that the isolated strain harbored genes for toxins A and B as well as binary toxin, and belonged to the ribotype 078. Based on these results, low occurrence of C. difficile in farm animals at slaughter and retail ground meat in Switzerland is postulated. However, further studies are necessary to confirm these preliminary data and to assess future trends.

[Cardiac amyloidosis]. / Le cas clinique du mois. Amyloïdose cardiaque de type AL: a propos d'un cas.

We present a case of a 54-year-old female presenting with renal failure and, two years later, heart failure, both due to primary systemic amyloidosis. The case gives us the opportunity to review the litterature on the topic.

[Interest of BNP value after cardiac resynchronisation therapy]. / Intérêt du dosage du "brain natriuretic peptide" (BNP) après resynchronisation cardiaque.

Cardiac resynchronisation therapy (CRT) induces, among responders, an early but sustained decrease of BNP levels. The changes of this parameter at 6 months, as well as its relative variations over the same time period, allow identification of the patients susceptible to benefit from CRT. Measurements of BNP levels might offer a useful tool for treatment optimisation in this particularly frail group of patients.

[Clinical case of the month. Constrictive pericarditis with a macroscopically normal pericardium: apropos of a case]. / Le cas clinique du mois. Péricardite constrictive à péricarde macroscopiquement normal: à propos d'un cas.

The diagnosis of constrictive pericarditis is not easy to make. This rare condition can be suggested by clinical, echocardiograohic, hemodynamic, and radiological signs. It must be distinguished from restrictive cardiomyopathy as therapeutic options are radically different. We present an ambiguous case of constrictive pericarditis with macroscopically normal pericardium recognized 10 years after open-chest cardiac surgery: a large pericardiectomy rapidly induced clinical improvement.

Modification of neutrophil function by plasma of rheumatoid arthritis patients treated with infliximab.

OBJECTIVE: To examine whether the release of superoxide anions from neutrophils of healthy donors was affected when incubated with plasma from infliximab-treated rheumatoid arthritis (RA) patients. METHODS: Fifteen consecutive seropositive RA patients were treated with 3mg/kg infliximab on weeks 0, 2, 6, and 14. Disease activity was assessed by DAS28 score and by IL-6 level. Neutrophils from healthy donors were incubated with plasma drawn before each infliximab treatment. PMA-stimulated superoxide release was measured by the ferricytochrome C reduction method. RESULTS: 53% of the patients had a favorable clinical response. IL-6 levels showed a significant decline at week two, with a gradual increase thereafter. Treatment with infliximab did not change the superoxide production. However, when the group was divided retrospectively to responders (DeltaDAS28 > -1.2) and non-responders (DeltaDAS28 < -1.2), two different patterns were seen, although the pre-treatment levels were similar: Among the responders IL-6 remained low at its 2 weeks level till week 14, while in the non responders IL-6 increased 3 times (P < 0.03) from week 2 to 14. The responders showed mild, but continuous, reduction of superoxide release, while in the non-responders it increased significantly from week 2 on. CONCLUSION: The reduction in IL-6 in RA sera following anti-TNFalpha therapy has little influence on the capacity of these sera to stimulate healthy neutrophils to produce superoxide, suggesting the existence of non-TNFalpha non-IL-6 dependent neutrophil-stimulating mediators in RA sera. The increasing level of IL-6 among the non-responders after initial dramatic decline might represent an escape phenomenon, possibly caused by alternative mediator(s). Clinically, this IL-6 "escape" might be used as a tool for early identification of responders from non-responders.

Unilateral pulmonary edema caused by paravalvular leakage recognized by bedside transesophageal echocardiography.

We describe a case of acute unilateral left pulmonary edema occuring in an old man one year after mitral valve replacement. Transesophageal echocardiography identified a paravalvular leakage with severe mitral regurgitant jet directed to both left pulmonary veins. A prompt surgical closure of the leakage by pericardial patch was decided with rapid clinical and radiological improvement.

Low-level exercise echocardiography detects contractile reserve and predicts reversible dysfunction after acute myocardial infarction: comparison with low-dose dobutamine echocardiography.

OBJECTIVES: The aim of this study was to evaluate low-level exercise echocardiography (LLEE) in detecting contractile reserve and predicting functional improvement of akinetic myocardium early after acute myocardial infarction (AMI). BACKGROUND: Experimental and clinical studies have shown that low-dose dobutamine enhances contractile function of dyssynergic but viable myocardium in patients with recent AMI. We hypothesized that endogenous catecholamines produced during a LLEE test could serve as a myocardial stressor to elicit contractile reserve. METHODS: Fifty-two consecutive patients with first AMI and > or =2 akinetic segments in the infarct-related territory underwent 5 +/- 2 days after AMI low-dose dobutamine echocardiography (LDDE) (5, 10 and 15 microg/kg/min) and LLEE (25 W during 3 min on a supine bicycle, with continuous echocardiographic recording). Both tests were performed on the same day, in random order. Follow-up echocardiography was obtained one month later. Regional wall thickening was semi-quantitatively assessed using a 16-segment, 5-grade scale model. Contractile reserve was defined as improvement in wall thickening of > or =1 grade. RESULTS: Mean increase in heart rate during stress tests was 15 +/- 7 beats/min with LLEE and 13 +/- 6 beats/min with LDDE (p = NS). Contractile reserve was detected in 119 (55%) of 217 akinetic segments at LLEE and in 137 (63%) segments at LDDE. At follow-up study, functional improvement was identified in 139 (64%) segments. Sensitivity, specificity and positive and negative predictive values for predicting functional recovery were 81%, 92%, 95% and 73%, respectively, for LLEE, and 91%, 86%, 92% and 84%, respectively, for LDDE. Moreover, there was a good correlation between systolic wall thickening measured in the center of the dyssynergic area during stress tests and at follow-up study: r = 0.77, p < 0.001 with exercise testing and r = 0.73, p < 0.001 with dobutamine testing. CONCLUSIONS: Low-level exercise echocardiography provides a promising alternative to LDDE for identifying myocardial viability and predicting reversible dysfunction early after AMI.

[Clinical value of cardiac resynchronization therapy in patients with congestive heart failure]. / Resynchronisation ventriculaire dans la décompensation cardiaque réfractaire.

Besides major progress in the pharmacologic treatment of severe chronic heart failure, cardiac resynchronization therapy (CRT) has developped over the last ten years. We report the follow-up of the 36 first patients with a CRT device implanted from July 2000 to November 2002 at the CHR de la Citadelle Hospital in Liege. After a mean follow up of 6 months, no death was observed. The functional benefit of resynchronization is validated by a significant improvement in the NYHA class, an increase in the walking distance measured by the six minute walk test from 268 +/- 103 to 342 +/- 106 meters (p < 0.004) and by a not significant rise in the VO2 max (from 11.1 +/- 2.8 to 14 +/- 10 ml/kg/min; P=0.1). The quality of life, assessed by the Minnesota-Living-In-CHF score, improves from 49 +/- 20 to 35 +/- 22 after the six month follow-up (P=0.02) The echocardiogram also shows a better left ventricular ejection fraction at six months, from 24 +/- 7% to 31 +/- 7% (P<0.05). Based on a better NYHA functional class, responders (n=24; 71%) and non responders (n=10; 29%) were compared; a correlation between the functional class change and the improvement of the ejection fraction was documented, but not with the reduction in QRS width. Our registry, with the potential pitfalls of a monocentric prospective study, confirms the feasability, safety and efficacy of CRT in severe chrbnic heart failure uncompletely corrected pharmocalogically. It remains however approximately 30% of non responding patients, in whom the current clinical studies should help identify the right criteria to predict and discriminate responders.

Paraquat-induced formation of leukotriene B4 in rat lungs: modulation by N-acetylcysteine.

The present work is focused on the formation of the inflammatory mediator leukotriene B4 (LTB4) in the lungs of paraquat (PQ)-intoxicated rats. The levels of LTB4 and the number of neutrophils in lung lavages of PQ-intoxicated rats, measured 12 h after 30 mg/kg PQ, increased significantly compared with those of control animals; administration of 50 mg/kg IP N-acetylcysteine (NAC), 8 h after PQ, inhibited this effect. The release of LTB4 from alveolar macrophages (AM) or alveolar epithelial type II cells from healthy animals incubated with PQ and/or NAC did not offer' an explanation for the effect of these chemicals on LTB4 in the bronchoalveolar lavage fluid (BALF). The PQ-enhanced, NAC-inhibited release of arachidonic acid (AA) by alveolar epithelial type II cells did, however, explain our in vivo results, when one assumes that the AM synthesize their 5-lipoxygenase products from alveolar epithelial cell-derived AA, an hypothesis demonstrated already by other researchers.

Role of stress echocardiography in heart failure.

Most patients presenting with heart failure have severe coronary artery disease. The identification of viable hibernating myocardium is of paramount clinical importance for a correct indication of revascularization. Contractile reserve may be identified when regional asynergy improves during low or moderate doses of dobutamine. Dipyridamole, given at infra-low dose, alone or preferably in association with a low dose of dobutamine, is another possible pharmacologic stress protocol. Dobutamine echocardiography has been found to be more specific than thallium scintigraphy for predicting functional recovery after revascularization. However, the absence of contractile reserve does not exclude the presence of myocardial viability: perfusion reserve may be too low because of a critical coronary artery stenosis, or profound ultrastructural changes of myocardial cells may be present, including significant loss of contractile material. Inotropic reserve can also be assessed by dobutamine stress echocardiography in patients with idiopathic cardiomyopathy. The evolution of hemodynamic variables can be measured during the stress test. Stress echocardiography, especially during exercise, could probably provide important information about heart failure associated with valvular heart disease.

Management of aortobronchial fistula with an aortic stent-graft.

Aortobronchial fistula presenting as massive hemoptysis is a rapidly fatal process that is extremely difficult to manage. We report a case in which endovascular occlusion of a fistula between a thoracic aortic pseudoaneurysm and lung was successfully managed by placement of an aortic endovascular stent-graft. Stent-grafting is a promising technique in managing complications of thoracic aneurysms and grafts.

Treatment of pulmonary artery compression due to fibrous mediastinitis with endovascular stent placement.

We present the case of a 32-year-old woman with high-grade right pulmonary artery stenosis secondary to fibrous mediastinitis. The patient was managed with balloon angioplasty and stent placement. Only 15 cases of this nature have been reported in the literature, and this is one of the first to be managed with endovascular stent placement.