190: In how many patients with Wolff-Parkinson-White syndrome-related adverse presentation isoproterenol infusion was required to reproduce the arrhythmia?

Electrophysiological study is the main method for the detection of patients with a Wolff-Parkinson-White syndrome (WPW) at risk of adverse presentation (resuscitated ventricular fibrillation (VF), documented life-threatening arrhythmia): the protocol is debated. The purpose of the study was to look in how many patients with WPW-related adverse presentation, atrial fibrillation (AF) or atrial tachycardia with the shortest RR cycle length (CL) with 1/1 conduction over accessory pathway (AP)<250msec was induced in control state (CS) and when isoproterenol was required.Methods63 patients, mean age 38±18, were referred for WPW-related adverse presentation (VF 6, other 56). EPS included in CS atrial pacing and measurement of the shortest CL with 1/1 conduction over AP and programmed stimulation with 1 and 2 extrastimuli. AP effective refractory period (ERP) was determined. In absence of induction of a tachycardia with a CL <250msec, isoproterenol (0.02 to 1μg. min-1) was infused to increase sinus rate to 130bpm; the protocol was repeated.ResultsMean shortest CL conducted over AP was 223±30msec in CS, 192±25msec after isoproterenol. APERP was 225±29msec in CS, 191±19msec after isoproterenol. Atrioventricular orthodromic tachycardia (AVRT) was induced in 34 patients (54%), antidromic tachycardia (ATD) in 13 (21%), AF in 43 (68%). Criteria for a malignant form (induction of AF or ATD with a shortest CL <250mesc) were noted in 42 patients (67%) in CS and were obtained after isoproterenol in remaining 21 patients (33%). Among these patients, 12 had inducible tachycardia in CS (AVRT (n=6), ATD (n=3), AF (n=3) but the shortest CL was >240msec. A tachycardia was only induced after isoproterenol in 9 patients (14%).ConclusionsInfusion of isoproterenol should be systematic when WPW is evaluated. EPS performed only in CS missed at least 14% of patients at risk of life-threatening arrhythmias who had no inducible supraventricular tachyarrhythmia and 33% of patients with a WPW without the classical criteria for a malignant form. Isoproterenol increased the sensitivity of EPS for the detection of malignant form from 67 to 100%

Using exoskeletons to assist medical staff during prone positioning of mechanically ventilated COVID-19 patients: a pilot study

International audienceWe conducted a pilot study to evaluate the potential and feasibility of back-support exoskeletons to help the caregivers in the Intensive Care Unit (ICU) of the University Hospital of Nancy (France) executing Prone Positioning (PP) maneuvers on patients suffering from severe COVID-19-related Acute Respiratory Distress Syndrome. After comparing four commercial exoskeletons, the Laevo passive exoskeleton was selected and used in the ICU in April 2020. The first volunteers using the Laevo reported very positive feedback and reduction of effort, confirmed by EMG and ECG analysis. Laevo has been since used to physically assist during PP in the ICU of the Hospital of Nancy, following the recrudescence of COVID-19, with an overall positive feedback

Antithrombotic management and outcomes of patients with atrial fibrillation treated with NOACs early at the time of market introduction:Main results from the PREFER in AF Prolongation Registry

International audienceAbstract The management of patients with atrial fibrillation (AF) has rapidly changed with increasing use of non-vitamin K antagonist oral anticoagulants (NOACs) and changes in the use of rhythm control therapy. The prevention of thromboembolic events European Registry in Atrial Fibrillation Prolongation Registry (PREFER Prolongation) enrolled consecutive patients with AF on NOACs between 2014 and 2016 in a multicentre, prospective, observational study with one-year follow-up, focusing on the time of introduction of NOACs. Overall, 3783 patients were enrolled, with follow-up information available in 3223 (85%). Mean age was 72.2 ± 9.4 years, 40% were women, mean CHA 2 DS 2 VASc score was 3.4 ± 1.6, and 2587 (88.6%) had a CHA 2 DS 2 VASc score ≥ 2. Rivaroxaban was used in half of patients, and dabigatran and apixaban were used in about a quarter of patients each; edoxaban was not available for use in Europe at the time. Major cardiovascular event rate was low: serious events occurred in 74 patients (84 events, 2%), including 24 strokes (1%), 62 major bleeds (2%), of which 30 were life-threatening (1%) and 3 intracranial (0.1%), and 28 acute coronary syndromes (1%). Mortality was 2%. Antiarrhythmic drugs were used in about 50% of patients, catheter ablation in 5%. Adverse events were low in this contemporary European cohort of unselected AF patients treated with NOACs already at the time of their first introduction, despite high thromboembolic risk

Myocardial deformation in malignant mitral valve prolapse: A shifting paradigm to dynamic mitral valve–ventricular interactions

ObjectivesThis study sought to assess the value of myocardial deformation using strain echocardiography in patients with mitral valve prolapse (MVP) and severe ventricular arrhythmia and to evaluate its impact on rhythmic risk stratification.BackgroundMVP is a common valvular affection with an overly benign course. Unpredictably, selected patients will present severe ventricular arrhythmia.MethodsPatients with MVP as the only cause of aborted SCD (MVP-aSCD: ventricular fibrillation and monomorphic and polymorphic ventricular tachycardia) with no other obvious reversible cause were identified. Nonconsecutive patients referred for the echocardiographic evaluation of MVP were enrolled as a control cohort and dichotomized according to the presence or absence of premature ventricular contractions (MVP-PVC or MVP-No PVC, respectively). All patients had a comprehensive strain assessment of mechanical dispersion (MD), postsystolic shortening, and postsystolic index (PSI).ResultsA total of 260 patients were enrolled (20 MVP-aSCD, 54 MVP-PVC, and 186 MVP-No PVC). Deformation pattern discrepancies were observed with a higher PSI value in MVP-aSCD than that in MVP-PVC (4.6 ± 2.0 vs. 2.9 ± 3.7, p = 0.014) and a higher MD value than that in MVP-No PVC (46.0 ± 13.0 vs. 36.4 ± 10.8, p = 0.002). In addition, PSI and MD increased the prediction of severe ventricular arrhythmia on top of classical risk factors in MVP. Net reclassification improvement was 61% (p = 0.008) for PSI and 71% (p = 0.001) for MD.ConclusionsIn MVP, myocardial deformation analysis with strain echocardiography identified specific contraction patterns with postsystolic shortening leading to increased values of PSI and MD, translating the importance of mitral valve–myocardial interactions in the arrhythmogenesis of severe ventricular arrhythmia. Strain echocardiography may provide important implications for rhythmic risk stratification in MVP

DMTs and Covid-19 severity in MS: a pooled analysis from Italy and France

We evaluated the effect of DMTs on Covid-19 severity in patients with MS, with a pooled-analysis of two large cohorts from Italy and France. The association of baseline characteristics and DMTs with Covid-19 severity was assessed by multivariate ordinal-logistic models and pooled by a fixed-effect meta-analysis. 1066 patients with MS from Italy and 721 from France were included. In the multivariate model, anti-CD20 therapies were significantly associated (OR&nbsp;=&nbsp;2.05, 95%CI&nbsp;=&nbsp;1.39–3.02, p&nbsp;&lt;&nbsp;0.001) with Covid-19 severity, whereas interferon indicated a decreased risk (OR&nbsp;=&nbsp;0.42, 95%CI&nbsp;=&nbsp;0.18–0.99, p&nbsp;=&nbsp;0.047). This pooled-analysis confirms an increased risk of severe Covid-19 in patients on anti-CD20 therapies and supports the protective role of interferon

Apport de l’électro-imagerie en électrophysiologie cardiaque pour la prise en charge des troubles du rythme ventriculaire graves

Ventricular arrhythmia remains a major public health problem, in particular ventricular tachycardias. These arrhythmias most often occur in patients who previously presented a myocardial infarction. Radiofrequency ablations represent the most effective treatment to suppress these tachycardias. However, the short- and long-term results are still imperfect, paving the way for improvements.We detail in this manuscript the physiopathological principles of occurrence of these ventricular tachycardias, the operating principles of the diagnostic tools used for their mapping, as well as the principles of destruction of the circuits of these arrhythmias. We review the contribution of imaging for the characterization of myocardial tissues and the identification of circuits. We present the specificities of the pace-mapping technique developed at the University Hospital of Nancy and which makes it possible to produce ventricular tachycardia maps in situations where the usual activation maps are not possible. This technique could also be considered for the analysis of the efficiency of the ablation lesions performed.We also present the current state of knowledge to determine the risk of an asymptomatic patient of developing ventricular tachycardia in the future. Risk stratification is currently based on left ventricular ejection fraction, but the growing importance of imaging, especially MRI, opens the way in the short term to individual risk determination. We present here our contribution to the improvement of the MRI tool and to the work of analyzing infarct scars to predict the risk of arrhythmias. Improvements in the prediction of individual risk are an essential step in the development of personalized medicineLes troubles du rythme ventriculaire demeurent un problème majeur de santé publique, en particulier les tachycardies ventriculaires (TV). Celles-ci surviennent la plupart du temps dans les suites d’un infarctus du myocarde. Les ablations par radiofréquence représentent le traitement le plus efficace pour supprimer ces tachycardies. Néanmoins, les résultats à court et long terme sont encore imparfaits ouvrant la voie à des améliorations.Nous détaillons dans ce manuscrit les principes physiopathologiques de survenue de ces tachycardies ventriculaires, les principes de fonctionnement des outils diagnostics utilisés pour leur cartographie, ainsi que les principes de destruction des circuits de ces arythmies. Nous exposons les spécificités de la technique de topostimulation mise au point au CHRU de Nancy et qui permet de réaliser des cartes de TV dans des situations où les cartes d’activation habituelles ne sont pas réalisables. Cette technique pourrait également être envisagée pour l’analyse de l’efficacité des lésions d’ablation réalisées.Nous exposons enfin l’état actuel des connaissances pour déterminer le risque d’un patient asymptomatique de présenter des TV dans le futur. La stratification du risque est actuellement basée sur la fraction d’éjection ventriculaire gauche, mais la place grandissante de l’imagerie, en particulier IRM, ouvre la voie à court terme à une détermination du risque individuel. Nous exposons notre contribution à l’amélioration de l’outil IRM et aux travaux d’analyse des cicatrices d’infarctus pour prédire le risque de trouble du rythme. Les améliorations dans la prédiction du risque individuel sont une étape essentielle dans le développement d’une médecine personnalisé