Impact of cardiac resynchronization therapy optimization inside a heart failure programme : a real‐world experience

Aims: This study sought to describe and evaluate the impact of a routine in‐hospital cardiac resynchronization therapy (CRT) programme, including comprehensive heart failure (HF) evaluation and systematic echo‐guided CRT optimization. Methods and results: CRT implanted patients were referred for optimization programme at 3 to 12 months from implantation. The program included clinical and biological status, standardized screening for potential cause of CRT non‐response and systematic echo‐guided atrioventricular and interventricular delays (AVd and VVd) optimization. Initial CRT‐response and improvement at 6 months post‐optimization were assessed with a clinical composite score (CCS). Major HF events were tracked during 1 year after optimization. A total of 227 patients were referred for CRT optimization and enrolled (71 ± 11 years old, 77% male, LVEF 30.6 ± 7.9%), of whom 111 (48.9%) were classified as initial non‐responders. Left ventricular lead dislodgement was noted in 4 patients (1.8%), and loss or ≤90% biventricular capture in 22 (9.7%), mostly due to arrhythmias. Of the 196 patients (86%) who could undergo echo‐guided CRT optimization, 71 (36.2%) required VVd modification and 50/144 (34.7%) AVd modification. At 6 months post‐optimization, 34.3% of the initial non‐responders were improved according to the CCS, but neither AVd nor VVd echo‐guided modification was significantly associated with CCS‐improvement. After one‐year follow‐up, initial non‐responders maintained a higher rate of major HF events than initial responders, with no significant difference between AVd/VVd modified or not. Conclusions: Our study supports the necessity of a close, comprehensive and multidisciplinary follow‐up of CRT patients, without arguing for routine use of echo‐guided CRT optimization

Human Septic Myopathy: Induction of Cyclooxygenase, Heme Oxygenase and Activation of the Ubiquitin Proteolytic Pathway

Background: Skeletal muscle failure and wasting are manifestations of sepsis in humans that leads to serious and prolonged complications. The authors investigated the role of the major proinflammatory and antiinflammatory pathways, namely the inducible isoforms cyclooxygenase (COX-2) and heme oxygenase (HO-1), and the ubiquitin proteolytic pathway in skeletal muscle of septic patients. Methods: Protein expression was detected by Western blot techniques. Muscle biopsies were taken from two muscle groups, rectus abdominis and vastus lateralis, of septic and control patients. Results: The study showed an increase in COX-2 and HO-1 proteins expression and an activation of the proteolytic ubiquitin pathway with a parallel increase in free ubiquitin and ubiquitinated proteins in skeletal muscle of septic but not of control patients. In addition, those patients who would die from septic shock expressed more COX-2 and HO-1 proteins in muscle biopsies than did those patients who would survive. Conclusions: This study showed a marked involvement of local proinflammatory and antiinflammatory pathways and, more importantly, demonstrated the existence of an active ubiquitin proteolytic pathway in skeletal muscle of septic patients. Activation of ubiquitin pathway could be involved in sepsis-related muscle catabolism and wasting

Validité des formules échocardiographiques estimant la pression auriculaire droite à partir de la veine cave inférieure chez 135 patients en insuffisance cardiaque

L estimation échocardiographique de la pression dans l oreillette (POD) est importante puisqu elle intervient dans l estimation des pressions pulmonaires (PAPS) qui ont un impact pronostic dans l insuffisance cardiaque (IC). L objectif de notre étude est de comparer les 7 formules publiées qui ont estimé échographiquement la pression dans l oreillette droite (POD) à partir des diamètres de la veine cave inférieure. 135 patients en IC stable ont bénéficié d une échocardiographie et d un cathétérisme cardiaque droit dans les 48h. Les 7 POD échocardiographiques ont été comparées à la POD du cathétérisme. Les PAPS ont été calculées à partir des 7 POD estimées. Les résultats ont montré une corrélation moyenne des 7 POD avec la référence. De plus les concordances étaient faibles pour discriminer les patients avec ou sans élévation des PAPS. Au final, le plus simple en terme de temps est d estimer la POD comme étant égale à 1OmmHg pour chaque patient indépendamment de la mesure de la VCI.PARIS13-BU Serge Lebovici (930082101) / SudocSudocFranceF

Optimisation of treatments for heart failure with reduced ejection fraction in routine practice: a position statement from a panel of experts Optimización de los tratamientos de la insuficiencia cardiaca con fracción de eyección reducida en la práctica diaria: propuesta de un grupo de expertos

International audienceMajor international practice guidelines recommend the use of a combination of 4 medication classes in the treatment of patients with heart failure with reduced ejection fraction (HFrEF) but do not specify how these treatments should be introduced and up-titrated. Consequently, many patients with HFrEF do not receive an optimized treatment regimen. This review proposes a pragmatic algorithm for treatment optimization designed to be easily applied in routine practice. The first goal is to ensure that all 4 recommended medication classes are initiated as early as possible to establish effective therapy, even at a low dose. This is considered preferable to starting fewer medications at a maximum dose. The second goal is to ensure that the intervals between the introduction of different medications and between different titration steps are as short as possible to ensure patient safety. Specific proposals are made for older patients (> 75 years) who are frail, and for those with cardiac rhythm disorders. Application of this algorithm should allow an optimal treatment protocol to be achieved within 2-months in most patients, which should the treatment goal in HFrEF