961-78 Importance of Left Ventricular Ejection Fraction and Signal Averaged Electrocardiogram but not of Coronary Artery Patency nor Holter Monitoring to Predict Severe Arrhythmic Events After a First Myocardial Infarction in the Thrombolytic Era

We followed-up 244 consecutive patients (210 men, mean age56±9 yrs) who survived the acute phase (alive after day 7) of a first anterior (N=102) or inferior (N=142) myocardial infarction (MI) with a mean follow-up (FU) delay of 57±18 months. In the acute phase, 97/244 patients (40%) received a thrombolytic therapy. Within the second and third week after admission, all patients underwent a Holter ECG monitoring graded by the Lown classification, a signal averaged electrocardiogram (SAECG) and a coronary angiography. Three parameters were measured by SAECG (predictor system, 40Hz high-pass filter): total QRS duration (QRSd), root mean square voltage of the last 40ms (RMS) and duration of the terminal low (<40 uV) amplitude signal (LAS). The number of diseased vessels as well as the infarct related artery (IRA) patency was evaluated by TIMI grading (TIMI 2 or 3=patent) and left ventricular ejection fraction (LVEF) was measured angiographically. Cox proportional hazards model was used for the statistical analysis.ResultsWe observed 18 arrhythmic events (AE): 10 sudden cardiac death and 8 ventricular tachycardia during the FU period. Statistical analysis identified 3 independent factors predictive of the occurence of an AE: 1) LVEF, with a risk multiplied by 1.9 for each 0.10 decrease in the LVEF value, 2) LAS, with a risk multiplied by 1.3 for each 5ms increase in LAS value and 3) absence of thrombolysis, with a risk multiplied by 3.9.ConclusionsAfter MI in the thrombolytic era the Holter ECG monitoring and the results of the coronary angiography do not predict the risk of an AE. LVEF, SAECG and absence of thrombolysis are the 3 independent predictors of such a risk

Arrhythmias in Patients With Valvular Heart Disease: Gaps in Knowledge and the Way Forward.

peer reviewedThe prevalence of both organic valvular heart disease (VHD) and cardiac arrhythmias is high in the general population, and their coexistence is common. Both VHD and arrhythmias in the elderly lead to an elevated risk of hospitalization and use of health services. However, the relationships of the two conditions is not fully understood and our understanding of their coexistence in terms of contemporary management and prognosis is still limited. VHD-induced left ventricular dysfunction/hypertrophy and left atrial dilation lead to both atrial and ventricular arrhythmias. On the other hand, arrhythmias can be considered as an independent condition resulting from a coexisting ischemic or non-ischemic substrate or idiopathic ectopy. Both atrial and ventricular VHD-induced arrhythmias may contribute to clinical worsening and be a turning point in the natural history of VHD. Symptoms developed in patients with VHD are not specific and may be attributable to hemodynamical consequences of valve disease but also to other cardiac conditions including arrhythmias which are notably prevalent in this population. The issue how to distinguish symptoms related to VHD from those related to atrial fibrillation (AF) during decision making process remains challenging. Moreover, AF is a traditional limit of echocardiography and an important source of errors in assessment of the severity of VHD. Despite recent progress in understanding the pathophysiology and prognosis of postoperative AF, many questions remain regarding its prevention and management. Furthermore, life-threatening ventricular arrhythmias can predispose patients with VHD to sudden cardiac death. Evidence for a putative link between arrhythmias and outcome in VHD is growing but available data on targeted therapies for VHD-related arrhythmias, including monitoring and catheter ablation, is scarce. Despite growing evidences, more research focused on the prognosis and optimal management of VHD-related arrhythmias is still required. We aimed to review the current evidence and identify gaps in knowledge about the prevalence, prognostic considerations, and treatment of atrial and ventricular arrhythmias in common subtypes of organic VHD

AGE AND GENDER-RELATED SYMPTOMS RECURRENCE AFTER AV NODE RE-ENTRANT TACHYCARDIA

International audienc

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%

Influence of cigarette smoking on rate of reopening of the infarct-related coronary artery after myocardial infarction: A multivariate analysis

AbstractObjectives. This study sought to determine whether the reopening of the infarct-related vessel is related to clinical characteristics or cardiovascular risk factors, or both.Background. In acute myocardial infarction, thrombolytic therapy reduces mortality by restoring the patency of the infarct-related vessel. However, despite the use of thrombolytic agents, the infarct-related vessel remains occluded in up to 40% of patients.Methods. We studied 295 consecutive patients with an acute myocardial infarction who underwent coronary angiography within 15 days (mean [±SD] 6.7 ± 3.2 days) of the onset of symptoms. Infarct-related artery patency was defined by Thrombolysis in Myocardial Infarction trial flow grade ≥ 2. Four cardiovascular risk factors—smoking, hypertension, hypercholesterolemin and diabetes mellitus—and eight different variables—age, gender, in-hospital death, history of previous myocardial infarction, location of current myocardial infarction, use of thrombolytic agents, time interval between onset of symptoms, thrombolytic therapy and coronary angiography—were recorded in all patients.Results. Thrombolysis in current smokers and anterior infarct location on admission were the three independent factors highly correlated with the patency of the infarct-related vessel (odds ratios 3.2, 3.0 and 1.9, respectively). In smokers, thrombolytic therapy was associated with a higher reopening rate of the infarct vessel, from 35% to 77% (p < 0.001). Nonsmokers did not benefit from thrombolytic therapy, regardless of infarct location.Conclusions. These observational data, if replicated, suggest that in patients with acute myocardial infarction, thrombolytic therapy may be most effective in current smokers, whereas non-smokers and ex-smokers may require other management strategies, such as emergency percutaneous transluminal coronary angioplasty

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

Radio-frequency ablation as primary management of well-tolerated sustained monomorphic ventricular tachycardia in patients with structural heart disease and left ventricular ejection fraction over 30%

Aims Patients with well-tolerated sustained monomorphic ventricular tachycardia (SMVT) and left ventricular ejection fraction (LVEF) over 30% may benefit from a primary strategy of VT ablation without immediate need for a ‘back-up' implantable cardioverter-defibrillator (ICD). Methods and results One hundred and sixty-six patients with structural heart disease (SHD), LVEF over 30%, and well-tolerated SMVT (no syncope) underwent primary radiofrequency ablation without ICD implantation at eight European centres. There were 139 men (84%) with mean age 62 ± 15 years and mean LVEF of 50 ± 10%. Fifty-five percent had ischaemic heart disease, 19% non-ischaemic cardiomyopathy, and 12% arrhythmogenic right ventricular cardiomyopathy. Three hundred seventy-eight similar patients were implanted with an ICD during the same period and serve as a control group. All-cause mortality was 12% (20 patients) over a mean follow-up of 32 ± 27 months. Eight patients (40%) died from non-cardiovascular causes, 8 (40%) died from non-arrhythmic cardiovascular causes, and 4 (20%) died suddenly (SD) (2.4% of the population). All-cause mortality in the control group was 12%. Twenty-seven patients (16%) had a non-fatal recurrence at a median time of 5 months, while 20 patients (12%) required an ICD, of whom 4 died (20%). Conclusion Patients with well-tolerated SMVT, SHD, and LVEF > 30% undergoing primary VT ablation without a back-up ICD had a very low rate of arrhythmic death and recurrences were generally non-fatal. These data would support a randomized clinical trial comparing this approach with others incorporating implantation of an ICD as a primary strateg

Pertinence de l'analyse ECG par les médecins en préhospitalier (Exemple dans le service du SAMU de Nancy)

Une des spécificités françaises consiste en l'existence des équipes SMUR qui permettent une présence médicale dès le lieu de prise en charge du patient. Les urgentistes sont alors confrontés à de nombreuses difficultés liées entre autres, à l'absence d'examens complémentaires qui leur sembleraient nécessaires dans les plus brefs délais. Cependant, ils peuvent se baser sur l'électrocardiogramme, examen paraclinique incontournable dans le cadre de la médecine d'urgence et a fortiori, préhospitalière. Il s'agit d'un examen très largement utilisé et dont le reste de la prise en charge peut dépendre de sa bonne interprétation. Ce travail de thèse a donc pour objectifs d'évaluer la pertinence de l'analyse des tracés ECG des urgentistes en la comparant avec celle d'un rythmologue, d'apprécier si l'introduction d'une grille d'aide à la lecture permet de diminuer le nombre d'erreurs (grâce à une analyse systématique de tous les éléments composant un tracé), de mettre en avant les pathologies qui sont le plus sources d'erreurs afin de mettre en place des formations spécialisées et, enfin, de sensibiliser les cardiologues et les médecins généralistes sur l'importance de l ECG de référence. La thèse s'organise en trois grandes parties : La première partie comporte des généralités sur la médecine préhospitalière et, de façon succincte, l'analyse des tracés électrocardiographiques. La deuxième partie traite du travail de recherche proprement dit. Il se déroule en plusieurs étapes, la première consistant en un état des lieux régional du ressenti et des possibilités locales par rapport à l ECG. La deuxième étape comprend deux phases, une basée sur l'analyse libre des tracés alors que la seconde contient une grille d'aide à la lecture. Les 240 ECG, pour lesquels les urgentistes ont rempli un questionnaire, sont ensuite analysés par le cardiologue. Ce dernier ne bénéficiant pas des mêmes éléments que l'urgentiste, nous avons recherché les diagnostics hospitaliers afin de faire la comparaison la plus exacte possible. Celle-ci se porte donc sur 166 dossiers. Notre travail se termine par une discussion portant à la fois sur nos résultats, à savoir qu'une grille d'aide à la lecture n'augmente pas la pertinence de l'analyse des tracés, mais aussi sur les perspectives d'évolution, tant sur le plan des formations mais aussi sur l'introduction d'une grille plus adaptée à la médecine d'urgence préhospitalière.NANCY1-SCD Medecine (545472101) / SudocNANCY1-Bib. numérique (543959902) / SudocSudocFranceF

Le defibrillateur implantable en prévention secondaire d'un trouble du rythme ventriculaire grave (analyse de 216 patients présentant une cardiopathie ischémique)

NANCY1-SCD Medecine (545472101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Apport de la technique de topostimulation ventriculaire pour localiser l'isthme des circuits de réentrée des tachycardies ventriculaires post infarctus

Cette étude rétrospective monocentrique porte sur 10 procédures d'ablation par radiofréquence, guidées par cartographie,électro-anatomique, de tachycardies ventriculaires (TV) post infarctus sélectionnées parmi 120 procédures d'ablation réalisées pour cette même indication entre 1998 et 2006 au CHU de Nancy. L'étude a pour but d'évaluer la valeur de la topostimulation ventriculaire gauche (VG) pour identifier, en rythme sinusal, la localisation de l'isthme des circuits de réentrée des TV post-infarctus. La méthodologie consistait à réaliser une cartographie 3D du VG (avec le système de cartographie CARTO®) en rythme sinusal puis en TV. Les sites de topostimulation VG repérés sur la carte en rythme sinusal permettaient de reconstruire une cartographie particulière du VG sur laquelle on pouvait visualiser la concordance morphologique - exprimée en pourcentage de corrélation - entre les ORS de l'ECG de surface, obtenus en différents sites de stimulation ventriculaires, aux ORS de la TV induite. L'analyse statistique montre que les sites de stimulation VG au niveau de la zone de sortie de l'isthme de la TV présentent une excellente concordance morphologique avec les ORS de la TV. La topostimulation permet ainsi de localiser la zone de sortie de l'isthme de la TV avec une très bonne sensibilité (>80%) et une très bonne spécificité (76-83%) pmtr des valeurs seuil de pourcentage de corrélation morphologique >75%. Par contre, la sensibilité, la spécificité et la valeur prédictive positive de la topostimulation sont médiocres pour l'identification de la zone centrale ou la zone d'entrée de l'isthme de la TV. Notre étude suggère que la technique de topostimulation ventriculaire comparative permet de localiser de façon assez précise les zones d'émergence "post-isthmique" des TV post infarctus. A partir de l'identification topographique de ces zones, il nous paraît possible de déduire la localisation de la zone d'entrée et donc de l'isthme des TV post infarctus dans la grande majorité des cas. Cette méthode polytechnique, mêlant topostimulation, cartographie 3D· et comparaison informatisée des signaux électrocardiographiques, paraît prometteuse pour le traitement endocavitaire des TV post infarctus instables. Des études spécifiques sont toutefois nécessaires pour valider cette méthode dans ce contexte.NANCY1-SCD Medecine (545472101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF