0578: Valvular atrial fibrillation and the risk of stroke and deaths: additional prognostic value of the CHA2DS2-VASc score

PurposeThe CHA2DS2-VASc score has been validated and is widely used to stratify the risk of thromboembolism in patients with non-valvular atrial fibrillation (AF). We sought to investigate whether this score could also be useful to predict the risk of stroke and death in patients with valvular AF.MethodsBetween 1998 and 2011, 1,592 consecutive patients, hospitalised for AF, 300 with valvular AF (mitral and/or aortic valve disease) and 1,292 with non-valvular AF were enrolled in the cohort. All patients were followed-up at least 6 months and cardiovascular events recorded. The end-point was defined as the first occurrence of stroke or death. The Cox analysis was adjusted on warfarin, antiplatelet and antiarrhythmic treatments at discharge.ResultsMean age was 73±14 years in valvular AF and 68±15 in non-valvular AF (p=0.0001). At baseline, in the valvular AF group CHA2DS2-VASc score were = 0 for 14 (5%) patients, = 1 for 28 (9%), ? 2 for 258 (86%). Non-valvular AF CHA2DS2-VASc scores were = 0 for 158 (12%), = 1 for 189 (15), ?2 for 945 (73%). The difference was statistically significant (p<0.0001). During a mean follow-up of 4.6±3.5 years, the patients with valvular AF experienced 154 (51%) and the patients with non-valvular AF experienced 409 (32%) strokes or deaths. The Kaplan-Meier curves (figure) show that patients with a CHA2DS2-VASc score ?2 were at higher risk of stroke or death. The adjusted Cox model, showed that valvular AF (HR, 1.57, 95%CI 1.30-1.89, p<0.0001) and a CHA2DS2-VASc score ?2 (HR, 5.30, 95%CI 3.77-7.45, p<0.0001) were predictors of risk of stroke or death.ConclusionThese results suggest that a CHA2DS2-VASc score ?2 is associated with a higher risk of stroke and deaths, at mid-term follow-up, in patients with valvular AF (figure next page).Abstract 0578 - Figure: Kaplan-Meier survival curve

Place of biomarkers and new echocardiographic techniques (3D, strain) in the evaluation of patients with atrial fibrillation

Objectifs. Le but de notre travail était de préciser la fonction atriale et d’évaluer le remodelage cavitaire au cours du suivi d’un patient suivi pour fibrillation atriale (FA). Contexte. Précédant l’apparition de la FA, la cardiomyopathie atriale correspond à un remodelage anatomique, fonctionnel et électrique de l’oreillette. L'amélioration de la caractérisation de la cardiomyopathie atriale en amont et/ou lors d’un épisode de FA pourrait améliorer sa prise en charge. Méthodes. Des patients en FA ont été étudiés sur le plan clinique, biologique (métabolomique) et échocardiographique (bidimensionnelle, tridimensionnelle et strain) pour préciser la fonction et le remodelage cavitaire au cours du suivi. Résultats. Nous avons montré que la restauration active d’un rythme sinusal chez un patient en FA a induit un remodelage reverse anatomique et/ou fonctionnel des cavités cardiaques et semble être corrélé à la régression des fuites fonctionnelles atrio-ventriculaires. Nous avons aussi identifié différentes variables cliniques, biologiques, métabolomiques et échocardiographiques associées au strain réservoir de l’oreillette gauche. L'approche combinée multiparamétrique semble être la plus précise pour prédire l'altération de la déformation myocardique de l’oreillette gauche dans le suivi (Surface sous la courbe ROC : 0.871). Conclusion. La restauration du rythme sinusal dans la FA devrait être discutée en pratique clinique pour chaque patient afin d’améliorer le remodelage reverse des cavités cardiaques et la sévérité des fuites fonctionnelles atrio-ventriculaires. Le strain OG pourrait constituer un intégrateur des multiples déterminants du stress myocardique dans la FA.Objectives. The aim of our studies was to evaluate atrial function and cavity remodeling during follow-up of patients with atrial fibrillation (AF). Background. Preceding the onset of AF, atrial cardiomyopathy corresponds to anatomic, functional, and electrical remodeling of the atria. Improved characterization of atrial cardiomyopathy anterior to and/or during an episode of AF may improve its management. Methods. AF subjects were studied with clinical, biological (metabolomics), and echocardiographical (2-dimensional, 3-dimensional, and strain) parameters to evaluate cavity function and cavity remodeling during follow-up. Results. We showed that active restoration of sinus rhythm in a patient with AF induced anatomic and/or functional reverse remodeling of the cardiac cavities and appeared to correlate with regression of atrioventricular functional regurgitation. We also identified different clinical, biological, metabolomic, and echocardiographic variables associated with left atrial reservoir strain. The combined multiparametric approach appears to be the most accurate in predicting alteration of left atrial myocardial strain in follow-up (Area Under the ROC Curve 0.871). Conclusion. Restoration of sinus rhythm in AF patients should be discussed in clinical practice for each patient to improve reverse cavity remodeling and functional regurgitation severity. Left atrial strain could be an integrator of multiple determinants of myocardial stress in AF

Apports des nouvelles techniques echocardiographiques (3d, strain) dans l'evaluation du risque thromboembolique chez les patients en fibrillation atriale

Objectives. The aim of our studies was to evaluate atrial function and cavity remodeling during follow-up of patients with atrial fibrillation (AF). Background. Preceding the onset of AF, atrial cardiomyopathy corresponds to anatomic, functional, and electrical remodeling of the atria. Improved characterization of atrial cardiomyopathy anterior to and/or during an episode of AF may improve its management. Methods. AF subjects were studied with clinical, biological (metabolomics), and echocardiographical (2-dimensional, 3-dimensional, and strain) parameters to evaluate cavity function and cavity remodeling during follow-up. Results. We showed that active restoration of sinus rhythm in a patient with AF induced anatomic and/or functional reverse remodeling of the cardiac cavities and appeared to correlate with regression of atrioventricular functional regurgitation. We also identified different clinical, biological, metabolomic, and echocardiographic variables associated with left atrial reservoir strain. The combined multiparametric approach appears to be the most accurate in predicting alteration of left atrial myocardial strain in follow-up (Area Under the ROC Curve 0.871). Conclusion. Restoration of sinus rhythm in AF patients should be discussed in clinical practice for each patient to improve reverse cavity remodeling and functional regurgitation severity. Left atrial strain could be an integrator of multiple determinants of myocardial stress in AF.Objectifs. Le but de notre travail était de préciser la fonction atriale et d’évaluer le remodelage cavitaire au cours du suivi d’un patient suivi pour fibrillation atriale (FA). Contexte. Précédant l’apparition de la FA, la cardiomyopathie atriale correspond à un remodelage anatomique, fonctionnel et électrique de l’oreillette. L'amélioration de la caractérisation de la cardiomyopathie atriale en amont et/ou lors d’un épisode de FA pourrait améliorer sa prise en charge. Méthodes. Des patients en FA ont été étudiés sur le plan clinique, biologique (métabolomique) et échocardiographique (bidimensionnelle, tridimensionnelle et strain) pour préciser la fonction et le remodelage cavitaire au cours du suivi. Résultats. Nous avons montré que la restauration active d’un rythme sinusal chez un patient en FA a induit un remodelage reverse anatomique et/ou fonctionnel des cavités cardiaques et semble être corrélé à la régression des fuites fonctionnelles atrio-ventriculaires. Nous avons aussi identifié différentes variables cliniques, biologiques, métabolomiques et échocardiographiques associées au strain réservoir de l’oreillette gauche. L'approche combinée multiparamétrique semble être la plus précise pour prédire l'altération de la déformation myocardique de l’oreillette gauche dans le suivi (Surface sous la courbe ROC : 0.871). Conclusion. La restauration du rythme sinusal dans la FA devrait être discutée en pratique clinique pour chaque patient afin d’améliorer le remodelage reverse des cavités cardiaques et la sévérité des fuites fonctionnelles atrio-ventriculaires. Le strain OG pourrait constituer un intégrateur des multiples déterminants du stress myocardique dans la FA

Left atrial spontaneous echocardiographic contrast independently predicts 5-year stroke/death in patients with non-valvular atrial fibrillation

BACKGROUND: Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) can be used to detect the presence of left atrial thrombus and left atrial spontaneous echocardiographic contrast (LASEC). OBJECTIVES: We sought to evaluate the prognostic value of TTE and TEE in predicting stroke and all-cause death at 5-year follow-up in patients with non-valvular atrial fibrillation (NVAF). METHODS: This study included patients hospitalized with electrocardiography-diagnosed NVAF in Saint Antoine University Hospital, Paris, between July 1998 and December 2011 who underwent TTE and TEE evaluation within 24 hours of admission. Cox proportionalhazards models were used to identify predictors of the composite outcome (stroke or all cause death). RESULTS: During 5 years of follow-up, stroke/death occurred in 185/903 patients (20.5%). By multivariable analysis, independent predictors of stroke/death were CHA2DS2-VASc score (hazard ratio [HR]: 1.35; 95% confidence interval [CI]: 1.25-1.47; p 20 cm2 (HR: 1.59; 95% CI: 1.08-2.35; p =0.018) moderate LASEC (HR: 1.72; 95% CI: 1.13-2.62; p =0.012) and severe LASEC (HR: 2.04; 95% CI: 1.16-3.58; p =0.013). Independent protective predictors were dyslipidemia (HR: 0.60; 95% CI: 0.43-0.83; p =0.002) and discharge prescription of antiarrhythmics (HR: 0.59; 95% CI: 0.40-0.87; p =0.008). Adding LASEC to the CHA2DS2-VASc score modestly improved predictive accuracy and risk classification, with a C index of 0.71 vs. 0.69 (p = 0.004). CONCLUSIONS: Presence of moderate/severe LASEC is a strong and independent predictor of stroke/death at 5-year follow-up in patients with NVAF. The inclusion of LASEC in stroke risk scores could improve risk stratification

Corrélation entre la présence de contraste spontané dans l’oreillette gauche et le risque d’AVC ou de décès chez des patients en fibrillation atriale

International audienceBackground: Transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) can be used to detect the presence of left atrial thrombus and left atrial spontaneous echocardiographic contrast (LASEC).Aim: To evaluate the prognostic value of TTE and TOE in predicting stroke and all-cause death at 5-year follow-up in patients with non-valvular atrial fibrillation (NVAF).Methods: This study included patients hospitalised with electrocardiography-diagnosed NVAF in Saint-Antoine University Hospital, Paris, between July 1998 and December 2011, who underwent TTE and TOE evaluation within 24hours of admission. Cox proportional-hazards models were used to identify predictors of the composite outcome (stroke or all-cause death).Results: During 5 years of follow-up, stroke/death occurred in 185/903 patients (20.5%). By multivariable analysis, independent predictors of stroke/death were CHA2DS2-VASc score (hazard ratio [HR] 1.35, 95% confidence interval [CI] 1.25-1.47; P20 cm2 (HR 1.59, 95% CI 1.08-2.35; P=0.018), moderate LASEC (HR 1.72, 95% CI 1.13-2.62; P=0.012) and severe LASEC (HR 2.04, 95% CI 1.16-3.58; P=0.013). Independent protective predictors were dyslipidaemia (HR 0.60, 95% CI 0.43-0.83; P=0.002) and discharge prescription of anti-arrhythmics (HR 0.59, 95% CI 0.40-0.87; P=0.008). Adding LASEC to the CHA2DS2-VASc score modestly improved predictive accuracy and risk classification, with a C index of 0.71 vs. 0.69 (P=0.004).Conclusions: In this retrospective monocentric study, the presence of moderate/severe LASEC was an independent predictor of stroke/death at 5-year follow-up in patients with NVAF. The inclusion of LASEC in stroke risk scores could modestly improve risk stratification.ContexteL’échocardiographie transthoracique (ETT) et transoesophagienne (ETO) peuvent être utilisées pour détecter la présence d’un thrombus et le contraste spontané dans l’oreillette gauche (CS OG).ObjectifLe but de l’étude est d’évaluer la valeur pronostique de l’ETT et de l’ETO, pour prédire la survenue d’un AVC et la mortalité toute cause à 5 ans de suivi, chez le patient en FA non valvulaire (FANV).MéthodesL’étude a inclus des patients hospitalisés pour FA non valvulaire (diagnostiqué par électrocardiogramme) au sein de l’hôpital universitaire Saint-Antoine, Paris, entre juillet 1998 et décembre 2011, et qui ont eu une ETT-ETO dans les 24 heures après l’admission. Un modèle de régression de Cox a été utilisé pour identifier les prédicteurs du critère composite: infarctus cérébral ou mortalité toute cause.RésultatsDurant les 5 années de suivi, l’infarctus cérébral/décès est survenu pour 185/903 patients (20,5%). En analyse multivariée, les facteurs prédicteurs indépendants d’infarctus cérébral/décès étaient le score CHA2DS2-VASc (hazard ratio [HR] 1,35, intervalle de confiance à 95% [IC 95%] 1,25–1,47; p 20 cm2 (HR 1,59, IC 95% IC 1,08–2,35; p = 0,018), un CS OG moyen (HR 1,72, IC 95% 1,13–2,62; p = 0,012) et un CS OG sévère (HR 2,04, IC 95% 1,16–3,58; p = 0,013). Les facteurs indépendants protecteurs étaient la dyslipidémie (HR 0,60, IC 95% 0,43–0,83; p = 0,002) et la prescription d’antiarythmiques à la sortie d’hospitalisation (HR 0,59, IC 95% 0,40–0,87; p = 0,008). L’ajout du CS OG au score CHA2DS2-VASc améliore modestement la précision et la classification du risque, avec un C index à 0,71 vs 0,69 (p = 0,004).ConclusionsLa présence d’un CS OG moyen/sévère est un prédicteur fort et indépendant d’infarctus cérébral/décès à 5 ans de suivi chez le patient en FA non valvulaire. L’inclusion du CS OG dans les scores de risque thromboembolique pourrait améliorer la stratification du risque

Fraction d’éjection ventriculaire gauche un marqueur de risqué additionnel dans la COVID-19

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Inverted Takotsubo Syndrome With HELLP Syndrome: A Case Report

International audienceBackground Takotsubo syndrome is an acute cardiac condition involving sudden, transient apical ballooning of the left ventricle of the heart that may be triggered by emotional stress and some non-cardiac conditions. Its diagnosis is based on clinical presentation, electrocardiogram, cardiac imaging and biomarkers. Case Summary Here, we present a novel and original case report of a patient presenting very soon in the post-partum period with an unusual form of Takotsubo syndrome without clinical symptoms of cardiac disease and accompanied by HELLP syndrome. The overall dynamics of the changes in troponin I, troponin T and NT-proBNP levels after delivery were generally similar, but the amount of troponin I was much greater than that of troponin T and troponin I was already elevated before delivery. NT-proBNP levels peaked around the same time as the troponins and the peak concentration was within the same range as that of troponin I. Discussion Our findings indicate that assaying circulating cardiac biomarkers, especially troponin I and NT-proBNP, may be a useful complement to non-invasive cardiac imaging including transthoracic echocardiography and cardiovascular magnetic resonance imaging, in the diagnosis of Takotsubo syndrome. They illustrate the importance of cardiac biomarkers in assisting diagnosis of this disease

Role of Cardiac Imaging in the Diagnosis of Immune Checkpoints Inhibitors Related Myocarditis

International audienceImmune checkpoint inhibitors (ICI) have constituted a paradigm shift in the management of patients with cancer. Their administration is associated with a new spectrum of immunerelated toxicities that can affect any organ. In patients treated with ICI, cardiovascular toxicities, particularly myocarditis, occur with a low incidence (<1%) but with a high fatality rate (30−50%). ICI-related myocarditis has been attributed to an immune infiltration, comprising of T-cells that are positive for CD3+, CD4+, CD8+, and macrophages that are positive for CD68. The diagnosis remains challenging and is made based on clinical syndrome, an electrocardiogram (ECG), biomarker data, and imaging criteria. In most clinical scenarios, endomyocardial biopsy plays a pivotal role in diagnosis, while cardiac magnetic resonance imaging (cMRI) has limitations that should be acknowledged. In this review, we discuss the role of medical imaging in optimizing the management of ICI related myocarditis, including diagnosis, prognostication, and treatment decisions

Biatrial remodelling in atrial fibrillation: A three-dimensional and strain echocardiography insight

International audienceBackground: Atrial remodelling has been poorly investigated in atrial fibrillation (AF), and few studies have focused on biatrial remodelling.Aim: To evaluate right atrial (RA) and left atrial (LA) remodelling in AF using global atrial reservoir strain and three-dimensional (3D) atrial volumes, according to rhythm outcome at mid-term follow-up.Methods: Two-dimensional and 3D transthoracic echocardiography (TTE) were performed within 24hours after admission (M0) and at 6-month follow-up (M6) in patients admitted for AF. RA and LA variables were assessed: body surface area-indexed maximum 3D volume (Max 3D RA Voli, Max 3D LA Voli) and minimum 3D volume (Min 3D RA Voli, Min 3D LA Voli); atrial emptying fraction (3D RAEF, 3D LAEF); atrial expansion index (3D RAEI, 3D LAEI); and global RA and LA reservoir strain.Results: Forty-eight consecutive patients were included prospectively. Three groups were identified depending on rhythm at M0 and M6: AF at M0 and sinus rhythm (SR) at M6 (AF-SR) in 25 (52.1%) patients; AF at M0 and AF at M6 (AF-AF) in 13 (27.1%) patients; and SR at M0 (spontaneous cardioversion before first TTE) and SR at M6 (SR-SR) in 10 (20.8%) patients. Between M0 and M6 in the AF-SR group, we found: significant decreases in Max 3D RA Voli (P=0.020), Min 3D RA Voli (P=0.0008), Max 3D LA Voli (P=0.001) and Min 3D LA Voli (P=0.0021); significant increases in 3D RAEF (P=0.037) and 3D RAEI (P=0.034); no significant differences in 3D LAEF and 3D LAEI; and significant increases in global RA and LA reservoir strain (both P<0.0001). There was no significant difference with regard to these variables in the AF-AF and SR-SR groups.Conclusion: 3D volume and strain analyses were useful in the evaluation of RA and LA reverse remodelling in successfully cardioverted patients with AF