Publications by authors named "Antoine Da Costa"

90 Publications

Predictors of high-degree conduction disturbances and pacemaker implantation after transcatheter aortic valve replacement: Prognostic role of the electrophysiological study.

Pacing Clin Electrophysiol 2021 Mar 19. Epub 2021 Mar 19.

Division of Cardiology, Jean Monnet University, Saint-Etienne, France.

Background: Predictors of high-degree atrioventricular block (HAVB) after transcatheter aortic valve replacement (TAVR) are recognized, but the electrophysiological study's (EPS) role is still a subject to debate. The objective of our study was to determine factors associated with PPM implantation including the potential role of EPS before and/or after TAVR.

Methods And Results: Seventy four consecutive patients (pts) were included and 21 pts (28.4%) received a PPM during the immediate postoperative follow-ups (until Day 5): HAVB in 15 pts (71.4%), prophylactic implantation due to a documented increased HV interval ≥ 95-100 ms plus LBBB in 2 pts (9.5%), a high-degree HV block evidenced at the EPS plus LBBB in 3 pts (14.3%) and one additional patient was implanted for AV-block in presence of AFib (4.8%). In the multivariate model 1 including parameters before TAVR, both prosthesis diameter and PR lengthening remained significantly associated with PPM as well RBBB. In the multivariate model 2 including parameters after TAVR, only HV remained significantly associated with the risk of PPM (OR = 1.15 (1.05-1.26), p = .004). When all the significant variables in models 1 and 2 were analyzed together in model 3, only HV after TAVR remained significantly associated with an increased risk of PPM.

Conclusions: In this prospective observational study, it was revealed that a Day 4-5 EPS is likely to more precisely stratify the risk of PPM implantation regarding its ability to discover asymptomatic severe infra-hisian conduction disturbances particularly in presence of LBBB. Multivariate analysis confirmed the prognostic value of HV alteration.
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http://dx.doi.org/10.1111/pace.14225DOI Listing
March 2021

Unsuspected somatic mosaicism for FBN1 gene contributes to Marfan syndrome.

Genet Med 2021 Jan 25. Epub 2021 Jan 25.

Université de Paris, Laboratory for Vascular Translational Science, INSERM U1148, Hôpital Bichat-Claude-Bernard, Paris, France.

Purpose: Individuals with mosaic pathogenic variants in the FBN1 gene are mainly described in the course of familial screening. In the literature, almost all these mosaic individuals are asymptomatic. In this study, we report the experience of our team on more than 5,000 Marfan syndrome (MFS) probands.

Methods: Next-generation sequencing (NGS) capture technology allowed us to identify five cases of MFS probands who harbored a mosaic pathogenic variant in the FBN1 gene.

Results: These five sporadic mosaic probands displayed classical features usually seen in Marfan syndrome. Combined with the results of the literature, these rare findings concerned both single-nucleotide variants and copy-number variations.

Conclusion: This underestimated finding should not be overlooked in the molecular diagnosis of MFS patients and warrants an adaptation of the parameters used in bioinformatics analyses. The five present cases of symptomatic MFS probands harboring a mosaic FBN1 pathogenic variant reinforce the fact that apparently asymptomatic mosaic parents should have a complete clinical examination and a regular cardiovascular follow-up. We advise that individuals with a typical MFS for whom no single-nucleotide pathogenic variant or exon deletion/duplication was identified should be tested by NGS capture panel with an adapted variant calling analysis.
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http://dx.doi.org/10.1038/s41436-020-01078-6DOI Listing
January 2021

FRAGILE: FRench Attitude reGistry in case of ICD LEad replacement.

Europace 2021 Mar;23(3):389-394

CHU La Timone Marseille, France.

Aims: FRench Attitude reGistry in case of ICD LEad replacement (FRAGILE) registry was set-up to describe the attitude in different French institutions in case of implantable cardioverter-defibrillator (ICD) lead replacement, extraction, or abandonment and to compare outcomes in both groups.

Methods And Results: Prospective observational study comparing two attitudes in case of ICD lead replacement, extraction, or abandonment. Primary endpoint describes the attitude in different French centres, collect parameters that may influence the decision. Secondary endpoint compares early and mid-term (2 years) complications in both groups.Between April 2013 and April 2017, 552 patients were included in 32 centres. 434 (78.6%) were male, mean patient's age was 60.3 ± 14.4 years. In 56.9% of the cases, the decision was to explant the lead. Patients in the extraction group were younger than in the abandonment group (56.7 ± 14.5 vs. 65 ± 12.7 P < 0.0001) and less likely to have comorbidities (46.5% vs. 58.3% of the patients P = 0.022). The mean lead dwelling time was significantly longer in the abandonment group as compared with the extraction group (7.6 ± 3.9 vs. 5.2 ± 3.1 years, P < 0.0001). There was no statistical difference between both groups concerning early and 2 years complications.

Conclusion: In this registry, the strategy in case of non-infected ICD lead replacement was mainly influenced by patient's age and comorbidities and lead dwelling time. No difference was observed in outcomes in both strategies.
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http://dx.doi.org/10.1093/europace/euaa290DOI Listing
March 2021

Wearable cardioverter-defibrillator in patients with a transient risk of sudden cardiac death: the WEARIT-France cohort study.

Europace 2021 Jan;23(1):73-81

Department of Cardiology, European Georges Pompidou Hospital, 75015 Paris, France.

Aims : We aimed to provide contemporary real-world data on wearable cardioverter-defibrillator (WCD) use, not only in terms of effectiveness and safety but also compliance and acceptability.

Methods And Results : Across 88 French centres, the WEARIT-France study enrolled retrospectively patients who used the WCD between May 2014 and December 2016, and prospectively all patients equipped for WCD therapy between January 2017 and March 2018. All patients received systematic education session through a standardized programme across France at the time of initiation of WCD therapy and were systematically enrolled in the LifeVest Network remote services. Overall, 1157 patients were included (mean age 60 ± 12 years, 16% women; 46% prospectively): 82.1% with ischaemic cardiomyopathy, 10.3% after implantable cardioverter-defibrillator explant, and 7.6% before heart transplantation. Median WCD usage period was 62 (37-97) days. Median daily wear time of WCD was 23.4 (22.2-23.8) h. In multivariate analysis, younger age was associated with lower compliance [adjusted odds ratio (OR) 0.97, 95% confidence interval (CI) 0.95-0.99, P < 0.01]. A total of 18 participants (1.6%) received at least one appropriate shock, giving an incidence of appropriate therapy of 7.2 per 100 patient-years. Patient-response button allowed the shock to be aborted in 35.7% of well-tolerated sustained ventricular arrhythmias and in 95.4% of inappropriate ventricular arrhythmia detection, finally resulting in an inappropriate therapy in eight patients (0.7%).

Conclusion: Our real-life findings reinforce previous studies on the efficacy and safety of the WCD in the setting of transient high-risk group in selected patients. Moreover, they emphasize the fact that when prescribed appropriately, in concert with adequate patient education and dedicated follow-up using specific remote monitoring system, compliance with WCD is high and the device well-tolerated by the patient.
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http://dx.doi.org/10.1093/europace/euaa268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7842091PMC
January 2021

Prognostic significance of a low T/R ratio in Brugada syndrome.

J Electrocardiol 2020 Nov - Dec;63:6-11. Epub 2020 Sep 2.

Service de Rythmologie, Centre de Référence National des Troubles du Rythme Cardiaque d'Origine Héréditaire de Lyon, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Avenue du Doyen Jean Lépine, 69500 Bron, France; Université de Lyon, Lyon, France. Electronic address:

Objectives: To determine the prognostic value of a low T/R ratio, defined as the amplitude ratio between the T waves and the R waves, in patients (pts) with a spontaneous type-1 Brugada pattern (SBT1).

Background: Abnormalities of myocardial repolarization may play a key role in the initiation of ventricular fibrillation (VF) in Brugada syndrome (BrS). Recent studies have shown that the height of the T waves and the T/R ratio are inversely proportional to sudden cardiac arrest (SCA) risk in early repolarization syndrome and hypertrophic cardiomyopathy.

Methods: In an international retrospective study, we reviewed 115 pts. (105 males, 91.3%). 45 had VF and/or SCA (38.7 ± 11.5 years old, all males), while 70 (49.3 ± 12.0 years, 10 women) remained free of ventricular arrhythmia. 6 ECG markers plus the T/R ratio in leads V5 & II were studied.

Results: The T/R ratio among leads II & V5 was significantly lower in the VF/SCA group (0.24 [0.14; 0.38]vs. 0.34 [0.24; 0.45]; p = 0.006). 44.4% of pts. in the VF/SCA group had a lowest T/R ratio among leads II & V5 ≤ 0.17 compared to 11.4% in the non-VF/SCA group (p < 0.001). In multivariate analysis, a lowest T/R ratio among leads II & V5 ≤ 0.17 was independently associated with VF/SCA (OR 6.10, 95% CI 1.92-19.40; p = 0.002). Type 1 Brugada pattern in the peripheral leads (OR 10.78) and early repolarization (OR 3.60) were other independent markers of VF/SCA.

Conclusion: A low T/R ratio among leads II & V5 is an independent marker for VF/SCA risk in patients with type-1 Brugada pattern.
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http://dx.doi.org/10.1016/j.jelectrocard.2020.08.023DOI Listing
September 2020

Long-Term Follow-Up of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator: The DAI-T4F Nationwide Registry.

Circulation 2020 Oct 1;142(17):1612-1622. Epub 2020 Oct 1.

Université de Paris, Institut National de la Santé et de la Recherche Médicale, Paris Cardiovascular Research Centre, France (V.W., A.A., S.B., M. Ladouceur, K.N., M.-C.P., A.S., X.J., E.M.).

Background: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce.

Methods: A Nationwide French Registry including all patients with tetralogy of Fallot with an ICD was initiated in 2010 by the French Institute of Health and Medical Research. The primary time to event end point was the time from ICD implantation to first appropriate ICD therapy. Secondary outcomes included ICD-related complications, heart transplantation, and death. Clinical events were centrally adjudicated by a blinded committee.

Results: A total of 165 patients (mean age, 42.2±13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (interquartile range) follow-up of 6.8 (2.5-11.4) years, 78 (47.3%) patients received at least 1 appropriate ICD therapy. The annual incidence of the primary outcome was 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively; =0.03). Overall, 71 (43.0%) patients presented with at least 1 ICD complication, including inappropriate shocks in 42 (25.5%) patients and lead dysfunction in 36 (21.8%) patients. Among 61 (37.0%) patients in primary prevention, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with, respectively, 0, 1, 2, or ≥3 guidelines-recommended risk factors. QRS fragmentation was the only independent predictor of appropriate ICD therapies (hazard ratio, 3.47 [95% CI, 1.19-10.11]), and its integration in a model with current criteria increased the 5-year time-dependent area under the curve from 0.68 to 0.81 (=0.006). Patients with congestive heart failure or reduced left ventricular ejection fraction had a higher risk of nonarrhythmic death or heart transplantation (hazard ratio, 11.01 [95% CI, 2.96-40.95]).

Conclusions: Patients with tetralogy of Fallot and an ICD experience high rates of appropriate therapies, including those implanted in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria including QRS fragmentation might improve risk stratification. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03837574.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.046745DOI Listing
October 2020

Impact of β-blocker therapy on right ventricular function in heart failure patients with reduced ejection fraction. A prospective evaluation.

Echocardiography 2020 09 20;37(9):1392-1398. Epub 2020 Aug 20.

Division of Cardiology CHU Saint Etienne, Jean Monnet University, Saint-Etienne, France.

Background: Beta-blocker (β-blocker) therapy has been shown to improve mortality and reduce hospitalizations in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Although the physiological action mechanisms of β-blockers are well described, their effects on right ventricular (RV) function have not been prospectively studied.

Objective: This prospective study aimed to (a) evaluate whether β-blocker therapy impacts RV remodeling based on echo parameters and (b) determine the predictive echo factors of β-blocker therapy response.

Methods: From September 2017 to September 2018, HF patients were prospectively enrolled using CIBIS criteria: Class II, III, or IV HF; left ventricular ejection fraction (LVEF) of ≤40%; hospitalized for HF within the previous 12 months. Echo evaluation was performed before initiating β-blocker therapy and 3 months after optimal dose adjustment. Based on previous studies, patients with (absolute) LVEF ≥ 5% improvement were considered significant β-blocker therapy responders.

Results: Overall, 40 patients (pts) completed the study, characterized as follows by age: 70 ± 10 years; gender: 10 women; cardiomyopathy etiology: idiopathic in 24 and ischemic in 16; NYHA Class: II in 22 and III in 10; LVEF: 32 ± 5%; and NTProBNP: 2665 ± 2400 pg/mL. The final population comprised 32 pts (79%), with eight (21%) excluded: two because of β-blocker therapy intolerance, one lost to follow-up, and five withdrew from the study. Under β-blocker therapy, several echo parameters significantly improved: LVEF from 31.7 ± 9 to 40.5 ± 9 (P < .0001); LV end-diastolic volume (EDV) from 154 ± 54 to 143 ± 45 mL (P = .06); LV end-systolic volume (ESV) from 107 ± 49 to 88 ± 37 mL (P = .0006); LV ES from 46 ± 11 to 64 ± 13 mL (P = .008); LV end-diastolic diameter (EDD) from 57 ± 9 to 54 ± 6 mm (P = .04); LV end-systolic diameter (ESD) from 48 ± 10 to 44 ± 7 mm (P = .007); and right ventricular systolic pressure (RV SP) from 39 ± 10 to 32 ± 8 mm Hg (P = .0001). Significant modifications were observed in terms of RV echo parameters: right ventricular (RV) size decreased from 30 ± 4 to 27 ± 5 mm (P = .03), while RV systolic function significantly improved based on tricuspid annular plane systolic excursion (TAPSE) (16.5 ± 4 vs. 19 ± 4 mm; 0.0006); DTI-derived tricuspid lateral annular systolic velocity wave (S') (10 ± 2 vs. 11.3 ± 3 cm/s; P = .03); and RIMP (Tei index) (0.5 ± 0.1 vs 0.46 ± 0.1; P = .04). RV 2D fractional area change (%) did not significantly differ despite a clear improvement tendency (35 ± 6 vs. 37 ± 4%; P = .1). No significant modifications were observed concerning LV diastolic parameters. Overall, β-blocker echo responders (n = 23/32; 72%) exhibited the same left and right echo parameters. No echo variables predicted the β-blocker response.

Conclusions: In HFrEF pts, β-blocker therapy significantly improves LV and RV systolic remodeling. Accordingly, β-blocker therapy could be applied as soon as possible in HFrEF patients with right ventricular dysfunction so as to limit RV remodeling.
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http://dx.doi.org/10.1111/echo.14813DOI Listing
September 2020

Comparison of Atrial Remodeling Caused by Sustained Atrial Flutter Versus Atrial Fibrillation.

J Am Coll Cardiol 2020 07;76(4):374-388

Department of Medicine and Research Center Montreal Heart Institute and Université de Montréal, Montréal, Québec, Canada; Department of Pharmacology and Therapeutics, McGill University Montréal, Montréal, Québec, Canada; Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Essen, Germany; IHU LIRYC and Fondation Bordeaux Université, Bordeaux, France. Electronic address:

Background: Atrial flutter (AFL) and atrial fibrillation (AF) are associated with AF-promoting atrial remodeling, but no experimental studies have addressed remodeling with sustained AFL.

Objectives: This study aimed to define the atrial remodeling caused by sustained atrial flutter (AFL) and/or atrial fibrillation (AF).

Methods: Intercaval radiofrequency lesions created a substrate for sustained isthmus-dependent AFL, confirmed by endocavity mapping. Four groups (6 dogs per group) were followed for 3 weeks: sustained AFL; sustained AF (600 beats/min atrial tachypacing); AF superimposed on an AFL substrate (AF+AFLs); sinus rhythm (SR) with an AFL substrate (SR+AFLs; control group). All dogs had atrioventricular-node ablation and ventricular pacemakers at 80 beats/min to control ventricular rate.

Results: Monitoring confirmed spontaneous AFL maintenance >99% of the time in dogs with AFL. At terminal open-chest study, left-atrial (LA) effective refractory period was reduced similarly with AFL, AF+AFLs and AF, while AF vulnerability to extrastimuli increased in parallel. Induced AF duration increased significantly in AF+AFLs and AF, but not AFL. Dogs with AF+AFLs had shorter cycle lengths and substantial irregularity versus dogs with AFL. LA volume increased in AF+AFLs and AF, but not dogs with AFL, versus SR+AFLs. Optical mapping showed significant conduction slowing in AF+AFLs and AF but not AFL, paralleling atrial fibrosis and collagen-gene upregulation. Left-ventricular function did not change in any group. Transcriptomic analysis revealed substantial dysregulation of inflammatory and extracellular matrix-signaling pathways with AF and AF+ALs but not AFL.

Conclusions: Sustained AFL causes atrial repolarization changes like those in AF but, unlike AF or AF+AFLs, does not induce structural remodeling. These results provide novel insights into AFL-induced remodeling and suggest that early intervention may be important to prevent irreversible fibrosis when AF intervenes in a patient with AFL.
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http://dx.doi.org/10.1016/j.jacc.2020.05.062DOI Listing
July 2020

Initial multicenter experience with a new high-density coloring module: impact for complex atrial arrhythmias interpretation.

J Interv Card Electrophysiol 2021 Mar 3;60(2):313-319. Epub 2020 Jul 3.

Cardiology Department, CHU Clermont-Ferrand, Clermont University, ISIT-CaVITI, 58 rue Montalembert, 63000 CHU, Clermont-Ferrand, France.

Background: High-density automated mapping of complex atrial tachycardias (ATs) requires accurate assessment of activation maps. A new local activation display module (HD coloring, Biosense Webster®) provides higher map resolution, a better delineation of potential block reducing color interpolation, and a new propagation display. We evaluated the accuracy of a dedicated local activation display compared with standard algorithm.

Methods: High-density maps from 10 AT were collected with a multipolar catheter and were displayed with standard activation or HD coloring. Six expert operators retrospectively analyzed activation maps and were asked to define (1) the tachycardia mechanism, (2) ablation target, and (3) level of difficulty to interpret those maps.

Results: Using HD coloring, operators were able to reach a correct diagnosis in 93% vs. 63%, p < 0.05 compared to standard activation maps. Time to diagnosis was shorter 1.9 ± 1.0 min vs. 3.9 ± 2.1 min, p < 0.05. Confidence level would have allowed ablation without necessity for entrainment maneuvers in 87% vs. 53%, p < 0.05. Operators would have needed to remap or proceed with multiple entrainments in 3% vs. 13% of cases, p < 0.05. Finally, ablation strategy was more accurately identified in 97% vs. 67%, p < 0.05.

Conclusion: Activation mapping with the new HD coloring module allowed a more accurate, reliable, and faster interpretation of complex ATs mechanisms compared to standard activation maps.
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http://dx.doi.org/10.1007/s10840-020-00802-1DOI Listing
March 2021

Cardiovascular disease events within 5 years after a diagnosis of breast cancer.

BMC Cancer 2020 Apr 21;20(1):337. Epub 2020 Apr 21.

Department of Vascular and Therapeutic Medicine, University Hospital of Saint-Etienne, Saint-Etienne, France.

Background: Concern for cardiovascular disease (particularly atrial fibrillation-AF) among women with breast cancer is becoming a major issue. We aimed at determining the incidence of cardiovascular disease events (AF, arterial and cardiac events, venous-thromboembolism-VTE) in patients diagnosed with breast cancer, and assessing potential risk factors.

Methods: We reviewed medical records of all patients diagnosed with breast cancer from 2010 to 2011 in our cancer center. Baseline characteristics of patients and tumors were collected. The main outcome was the occurrence of cardiovascular disease events (AF, VTE, arterial and cardiac events) during the 5-years follow-up.

Results: Among the 682 breast cancer patients, 22 (3.2%) patients had a history of atrial fibrillation. Thirty-four patients (5%) presented at least one cardiovascular disease event, leading to a cumulative incidence of 5.8% events at 5-years ([3.8-7.7] CI 95%), with most of them occurring in the first 2 years. AF cumulative incidence was 1.1% ([0.1-2.1] CI 95%). Factors associated with the occurrence of cardiovascular disease events (including AF) were an overexpression of HER-2 (HR 2.6 [1.21-5.56] p < 0.011), UICC-stage III tumors or more (HR 5.47 [2.78-10.76] p < 0.001) and pre-existing cardiovascular risk factors (HR 2.91 [1.36-6.23] p < 0.004).

Conclusion: The incidence of cardiovascular disease events was 5.8% ([3.8-7.7] CI 95%), with HER-2 over-expression, UICC-stage III tumors or more and pre-existing cardiovascular diseases being associated with them. These findings call for the development of preventive strategies in patients diagnosed with breast cancer.
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http://dx.doi.org/10.1186/s12885-020-06838-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216603PMC
April 2020

Adenosine usage during AF ablation in Europe and selected long-term findings from the ESC-EHRA EORP Atrial Fibrillation Ablation Long-Term registry.

J Interv Card Electrophysiol 2020 Apr 30. Epub 2020 Apr 30.

Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.

Background: Adenosine can be used to reveal dormant pulmonary vein (PV) conduction after PV isolation (PVI). This study presents a subanalysis of real-world 1-year follow-up data from the ESC-EHRA EORP Atrial Fibrillation (AF) Ablation Long-Term registry to analyze the usage of adenosine during PVI treatment in terms of rhythm outcome and safety.

Methods: The registry consists of 104 participating centers in 27 countries within the European Society of Cardiology. The registry data was split into an adenosine group (AG) and no-adenosine group (NAG). Procedure characteristics and patient outcome were compared.

Results: Adenosine was administered in 10.8% of the 3591 PVI patients included in the registry. Spain, the Netherlands, and Italy included the majority of adenosine cases (48.8%). Adenosine was applied more often in combination with open irrigation radiofrequency (RF) energy (74.7%) and less often in combination with nonirrigated RF energy (1.6%). After 1 year, a higher percentage of the AG was free from AF compared with the NAG (68.9% vs 59.1%, p < 0.001). Adenosine was associated with better rhythm outcome in RF ablation procedures, but not in cryo-ablation procedures (freedom from AF: RF: AG: 70.9%, NAG: 58.1%, p < 0.001, cryo: AG: 63.9%, NAG: 63.8%, p = 0.991).

Conclusions: The use of adenosine was associated with a better rhythm outcome after 1 year follow-up and seems more useful in patients treated with RF energy compared with patients treated with cryo energy. Given the improved rhythm outcome at 1-year follow-up, it seems reasonable to encourage the use of adenosine during RF AF ablation.
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http://dx.doi.org/10.1007/s10840-020-00744-8DOI Listing
April 2020

Screening Rheumatic Heart Disease in 1530 New Caledonian Adolescents.

J Am Heart Assoc 2020 05 26;9(9):e015017. Epub 2020 Apr 26.

Department of Cardiology Faculty of Medicine Jacques Lisfranc University Lyon-Saint-Etienne Saint-Etienne France.

BACKGROUND In New Caledonia, a South Pacific archipelago whose inhabitants comprise Melanesians, Europeans/whites, Wallisians, Futunans, Polynesians, and Asians, the prevalence of rheumatic heart disease (RHD) is 0.9% to 1% at ages 9 and 10. It could be higher at the age of 16, but this remains to be verified. METHODS AND RESULTS A total of 1530 Melanesian, Métis, white, Wallisian, Futunan, Polynesian, and Asian adolescents benefited from a transthoracic echocardiogram. Definite or borderline RHD, nonrheumatic valve lesions, congenital heart defects, family and personal history of acute rheumatic fever, and socioeconomic factors were collected. The prevalence of cardiac abnormalities was 8.1%, made up of 4.1% RHD including 2.4% definite and 1.7% borderline RHD, 1.7% nonrheumatic valve lesions, and 2.3% congenital anomalies. In whites and Asians, there were no cases of RHD. RHD was higher in the Wallisian, Futunan, and Polynesian group (7.6%) when compared with Melanesians (5.3%) and Métis (2.9%). The number of nonrheumatic valve lesions was not statistically different in the different ethnicities. The prevalence of RHD was higher in adolescents with a personal history of acute rheumatic fever, in those living in overcrowded conditions, and in those whose parents were unemployed or had low-income occupations, such as the farmers or manual workers. CONCLUSIONS RHD was 4 times higher in adolescents at age 16 than at ages 9 and 10 (4.1% versus 0.9%-1%). No cases of RHD were observed in whites and Asians. The determining factors were history of acute rheumatic fever and socioeconomic factors.
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http://dx.doi.org/10.1161/JAHA.119.015017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428581PMC
May 2020

High Risk of Sustained Ventricular Arrhythmia Recurrence After Acute Myocarditis.

J Clin Med 2020 Mar 20;9(3). Epub 2020 Mar 20.

Cardiology Department, Dijon Bourgogne University Hospital, 21000 Dijon, France.

Acute myocarditis is associated with cardiac arrhythmia in 25% of cases; a third of these arrhythmias are ventricular tachycardia (VT) or ventricular fibrillation (VF). The implantation of a cardiac defibrillator (ICD) following sustained ventricular arrhythmia remains controversial in these patients. We sought to assess the risk of major arrhythmic ventricular events (MAEs) over time in patients implanted with an ICD following sustained VT/VF in the acute phase of myocarditis compared to those implanted for VT/VF occurring on myocarditis sequelae. Our retrospective observational study included patients implanted with an ICD following VT/VF during acute myocarditis or VT/VF on myocarditis sequelae, from 2007 to 2017, in 15 French university hospitals. Over a median follow-up period of 3 years, MAE occurred in 11 (39%) patients of the acute myocarditis group and 24 (60%) patients of the myocarditis sequelae group. Kaplan-Meier MAE rate estimates at one and three years of follow-up were 19% and 45% in the acute group, and 43% and 64% in the sequelae group. Patients who experienced sustained ventricular arrhythmias during acute myocarditis had a very high risk of VT/VF recurrence during follow-up. These results show that the risk of MAE recurrence remains high after resolution of the acute episode.
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http://dx.doi.org/10.3390/jcm9030848DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141537PMC
March 2020

Management of Left Ventricular Thrombi with Direct Oral Anticoagulants: Retrospective Comparative Study with Vitamin K Antagonists.

Clin Drug Investig 2020 Apr;40(4):343-353

Division of Cardiology, Jean Monnet University, Saint-Etienne Cedex 2, Loire, France.

Background And Objectives: The efficacy of direct oral anticoagulants (DOACs) in the management of left ventricular (LV) thrombi remains to be determined, especially in patients with ischemic cardiomyopathy. This retrospective study sought to compare the efficacy of vitamin K antagonists (VKAs) and DOACs in patients with LV thrombi and evaluate the rate of LV thrombus resolution after adjusting anticoagulation.

Methods: This observational retrospective study included patients admitted to our institution for LV thrombus between January 2010 and August 2019. The rate of LV thrombus resolution was compared between VKAs and DOACs. Patients without thrombus resolution with DOAC treatment were switched to VKA agents in order to obtain an international normalized ratio (INR) of 3-4.

Results: Between January 2010 and August 2019, 59 consecutive patients with LV thrombi detected by transthoracic echocardiography were included in the study. The mean age was 62 ± 14 years and 16.9% were women. The circumstances of LV thrombus discovery were as follows: acute myocardial infarction or ischemic myocardiopathy (n = 22), stroke (n = 6), chest pain (n = 7), heart failure (n = 11), transthoracic echocardiographic evaluation (n = 11), and ventricular arrhythmias (n = 2). The proportion of patients on DOACs was 28.8% (n = 17), while that of those on VKAs was 71.2% (n = 42). Thrombus resolution was obtained in 70.6% (12/17) of patients on DOACs and in 71.4% (30/42) of those on VKAs (p = 0.9). Patients who failed to respond to DOAC treatment were treated with VKAs, and following this treatment adjustment all LV thrombi were dissolved in the DOAC group (5/5). Five embolic events (8.4% of stroke) occurred before the treatment initiation and six with anticoagulants (2/17 with DOACs [11.8%] and 4/42 with VKAs [9.5%]; p = 0.8).

Conclusions: This retrospective observational study found a similar efficacy between DOAC and VKA agents in patients with LV thrombi (70.6% vs. 71.5%); however, when the thrombus remains, VKAs are still the standard of care as it is possible to control INR levels (3-4) with them.
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http://dx.doi.org/10.1007/s40261-020-00898-3DOI Listing
April 2020

Role of atrial arrhythmia and ventricular response in atrial fibrillation induced atrial remodelling.

Cardiovasc Res 2021 Jan;117(2):462-471

Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, 5000 Belanger Street, Montreal H1T 1C8, Quebec, Canada.

Aims: No studies have assessed the specific contributions of atrial fibrillation (AF)-related atrial vs. associated ventricular arrhythmia to remodelling. This study assessed the roles of atrial arrhythmia vs. high ventricular rate in AF-associated remodelling.

Methods And Results: Four primary dog-groups (12/group) were subjected to 3-week pacing: 600-b.p.m. atrial tachypacing maintaining AF [AF w/o- atrioventricular block (AVB)]; atrial tachypacing with atrioventricular-node ablation (AF+AVB) and ventricular-demand pacing (80 b.p.m.); 160-b.p.m. ventricular-tachypacing (V160) reproducing the response rate during AF; and sinus rhythm with AVB/ventricular-pacing at 80-b.p.m. (control group). At terminal study, left-atrial (LA) effective refractory period (ERP) was reduced equally in both AF groups (w/o-AVB and AF+AVB). AF-inducibility was increased strongly in AF groups (w/o-AVB and AF+AVB) and modestly in V160. AF duration was significantly increased in AF w/o-AVB but not in AF+AVB or V160. Conduction velocity was decreased in AF w/o-AVB, to a greater extent than in AF+AVB and V160. Atrial fibrous-tissue content was increased in AF w/o-AVB, AF+AVB and V160, with collagen-gene up-regulation only in AF w/o-AVB. Connexin43 gene expression was reduced only in AF w/o-AVB. An additional group of 240-b.p.m. ventricular tachypacing dogs (VTP240; to induce heart failure) was studied: vs. other tachypaced groups, VTP240 caused greater fibrosis, but no change in LA-ERP or AF-inducibility. VTP240 also increased AF duration, strongly decreased left ventricular ejection fraction, and was the only group with LA natriuretic-peptide activation.

Conclusion: The atrial tachyarrhythmia and rapid ventricular response during AF produce distinct atrial remodelling; both contribute to the arrhythmogenic substrate, providing new insights into AF-related remodelling and novel considerations for ventricular rate-control.
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http://dx.doi.org/10.1093/cvr/cvaa007DOI Listing
January 2021

The European Society of Cardiology Cardiac Resynchronization Therapy Survey II: A comparison of cardiac resynchronization therapy implantation practice in Europe and France.

Arch Cardiovasc Dis 2019 Nov 6;112(11):713-722. Epub 2019 Nov 6.

Department of Cardiology and Vascular Diseases, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France. Electronic address:

Background: The first European Cardiac Resynchronization Therapy (CRT) Survey, conducted in 2008-2009, showed considerable variations in guideline adherence and implantation practice. A second prospective survey (CRT Survey II) was then performed to describe contemporary clinical practice regarding CRT among 42 European countries.

Aim: To compare the characteristics of French CRT recipients with the overall European population of CRT Survey II.

Methods: Demographic and procedural data from French centres recruiting all consecutive patients undergoing either de novo CRT implantation or an upgrade to a CRT system were collected and compared with data from the European population.

Results: A total of 11,088 patients were enrolled in CRT Survey II, 754 of whom were recruited in France. French patients were older (44.7% aged≥75 years vs 31.1% in the European group), had less severe heart failure symptoms, a higher baseline left ventricular ejection fraction and fewer co-morbidities. Additionally, French patients had a shorter intrinsic QRS duration (19.1% had a QRS<130ms vs 12.3% in the European cohort). Successful implantation rates were similar, but procedural and fluoroscopy times were shorter in France. French patients were more likely to receive a CRT pacemaker than European patients overall. Of note, antibiotic prophylaxis was reported to be administered less frequently in France, and a higher rate of early device-related infection was observed. Importantly, French patients were less likely to receive optimal drugs for treating heart failure at hospital discharge.

Conclusion: This study highlights contemporary clinical practice in France, and describes substantial differences in patient selection, implantation procedure and outcomes compared with the other European countries participating in CRT Survey II.
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http://dx.doi.org/10.1016/j.acvd.2019.09.005DOI Listing
November 2019

Impact of sacubitril/valsartan on echo parameters in heart failure patients with reduced ejection fraction a prospective evaluation.

Int J Cardiol Heart Vasc 2019 Dec 3;25:100418. Epub 2019 Sep 3.

Division of Cardiology, Jean Monnet University, Saint-Etienne, France.

Background: Sacubitril/valsartan has been shown to improve mortality and reduce hospitalizations in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Although the physiological action mechanisms of sacubitril/valsartan are well described, its effects on left ventricular (LV) remodelling and other echocardiographic (echo) parameters have not been prospectively studied.

Objective: The aim of this prospective study was to: McMurray et al. (2012) [1] evaluate if sacubitril/valsartan impacts LV remodelling based on echo parameters; Ponikowski et al. (2016) [2] identify the predictive factors of sacubitril/valsartan response or intolerance.

Methods: From May 2017 to September 2018, 52 HF patients were prospectively enrolled using PARADIGM-HF criteria: Class II, III, or IV HF; ejection fraction (EF) of 40% or less; hospitalized for HF within the previous 12 months. Echo evaluation was performed before initiating sacubitril/valsartan and 3 months after optimal dose adjustment. Based on previous studies, patients with (absolute) improvement in left ventricular ejection fraction (LVEF) ≥ 5% were considered significant sacubitril/valsartan responders.

Results: The 52 patients completing the study were characterized by age: 70 ± 10 years; gender: 11women; aetiology: idiopathic in 20 and ischaemic in 32; NYHA Class: II in 17 and III in 35; LVEF: 32 ± 5%; NTProBNP: 1805 ± 1914 pg/mL. The final population comprised 41 pts (79%), as 11 (21%) did not tolerate sacubitril/valsartan therapy. Under sacubitril/valsartan, several echo parameters significantly improved: LVEF from 32.6 ± 5 to 36 ± 6% ( < 0.0001); LVES volume from 117 ± 40 to 108 ± 46 mL ( = 0.0051); SEV from 59 ± 12 to 64 ± 13 ( = 0.0061); LVEDD from 60 ± 4 to 57 ± 5 mm ( = 0.0002); mean right ventricular systolic pressure (RVSP) from 39 ± 10 to 32 ± 8 ( = 0.0001). No significant modifications were observed concerning LV diastolic parameters or RV echo parameters. Sacubitril/valsartan echo responders (n = 18/41; 42%) had less severe LV remodelling, as shown by LVEDV: 144 ± 37 vs. 193 ± 47 mL,  = 0.0009; LVESV: 96 ± 28 vs. 133 ± 42 mL;  = 0.003; LVTDD: 61 ± 4 vs. 57 ± 5 mm;  = 0.02; significant mitral regurgitation: 6/18 (33%) vs. 16/23 (69%),  = 0.02; no diastolic LV or RV parameters impacted sacubitril/valsartan response. Predictors of sacubitril/valsartan intolerance were baseline creatinine level: 137 ± 99 vs. 100 ± 24,  = 0.03; LVEF: 29 ± 6 vs. 33 ± 5%;  = 0.04.

Conclusions: In HFrEF patients, sacubitril/valsartan significantly improves LV systolic remodelling, without any significant effects on LV diastolic or RV systolic echo parameters. Sacubitril/valsartan responders exhibit both less severe LV remodelling and less significant mitral regurgitation. Accordingly, sacubitril/valsartan could be used as soon as possible in HFrEF patients in order to limit LV remodelling, while precluding non-response or intolerance.
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http://dx.doi.org/10.1016/j.ijcha.2019.100418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6728827PMC
December 2019

Prediction of ventricular arrhythmias in patients with a spontaneous Brugada type 1 pattern: the key is in the electrocardiogram.

Europace 2019 Sep;21(9):1400-1409

Service de Rythmologie, Centre National de Référence des Troubles du Rythme Cardiaque Héréditaires de Lyon, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Avenue du Doyen Jean Lépine, 69500 Bron, France & Université de Lyon, Lyon, France.

Aims: There is currently no reliable tool to quantify the risks of ventricular fibrillation or sudden cardiac arrest (VF/SCA) in patients with spontaneous Brugada type 1 pattern (BrT1). Previous studies showed that electrocardiographic (ECG) markers of depolarization or repolarization disorders might indicate elevated risk. We aimed to design a VF/SCA risk prediction model based on ECG analyses for adult patients with spontaneous BrT1.

Methods And Results: This retrospective multicentre international study analysed ECG data from 115 patients (mean age 45.1 ± 12.8 years, 105 males) with spontaneous BrT1. Of these, 45 patients had experienced VF/SCA and 70 patients did not experience VF/SCA. Among 10 ECG markers, a univariate analysis showed significant associations between VF/SCA and maximum corrected Tpeak-Tend intervals ≥100 ms in precordial leads (LMaxTpec) (P < 0.001), BrT1 in a peripheral lead (pT1) (P = 0.004), early repolarization in inferolateral leads (ER) (P < 0.001), and QRS duration ≥120 ms in lead V2 (P = 0.002). The Cox multivariate analysis revealed four predictors of VF/SCA: the LMaxTpec [hazard ratio (HR) 8.3, 95% confidence interval (CI) 2.4-28.5; P < 0.001], LMaxTpec + ER (HR 14.9, 95% CI 4.2-53.1; P < 0.001), LMaxTpec + pT1 (HR 17.2, 95% CI 4.1-72; P < 0.001), and LMaxTpec + pT1 + ER (HR 23.5, 95% CI 6-93; P < 0.001). Our multidimensional penalized spline model predicted the 1-year risk of VF/SCA, based on age and these markers.

Conclusion: LMaxTpec and its association with pT1 and/or ER indicated elevated VF/SCA risk in adult patients with spontaneous BrT1. We successfully developed a simple risk prediction model based on age and these ECG markers.
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http://dx.doi.org/10.1093/europace/euz156DOI Listing
September 2019

An N-/L-type calcium channel blocker, cilnidipine, suppresses autonomic, electrical, and structural remodelling associated with atrial fibrillation.

Cardiovasc Res 2019 Dec;115(14):1975-1985

Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, Belanger St E, Montreal, Quebec, Canada.

Aims: Autonomic dysfunction can promote atrial fibrillation (AF) and results from AF-related remodelling. N-type Ca2+-channels (NTCCs) at sympathetic nerve terminals mediate Ca2+-entry that triggers neurotransmitter release. AF-associated remodelling plays an important role in AF pathophysiology but the effects of NTCC inhibition on such remodelling is unknown. Here, we investigated the ability of a clinically available Ca2+-channel blocker (CCB) with NTCC-blocking activity to suppress the arrhythmogenic effects of AF-promoting remodelling in dogs.

Methods And Results: Mongrel dogs were kept in AF by right atrial tachypacing at 600 bpm. Four groups were studied under short-term AF (7 days): (i) Shams, instrumented but without tachypacing (n = 5); (ii) a placebo group, tachypaced while receiving placebo (n = 6); (iii) a control tachypacing group receiving nifedipine (10 mg orally twice-daily; n = 5), an L-type CCB; and (iv) a cilnidipine group, subjected to tachypacing and treatment with cilnidipine (10 mg orally twice-daily; n = 7), an N-/L-type CCB. With cilnidipine therapy, dogs with 1-week AF showed significantly reduced autonomic changes reflected by heart rate variability (decreases in RMSSD and pNN50) and plasma norepinephrine concentrations. In addition, cilnidipine-treated dogs had decreased extracellular matrix gene expression vs. nifedipine-dogs. As in previous work, atrial fibrosis had not yet developed after 1-week AF, so three additional groups were studied under longer-term AF (21 days): (i) Shams, instrumented without tachypacing or drug therapy (n = 8); (ii) a placebo group, tachypaced while receiving placebo (n = 8); (iii) a cilnidipine group, subjected to tachypacing during treatment with cilnidipine (10 mg twice-daily; n = 8). Cilnidipine attenuated 3-week AF effects on AF duration and atrial conduction, and suppressed AF-induced increases in fibrous-tissue content, decreases in connexin-43 expression and reductions in sodium-channel expression.

Conclusions: Cilnidipine, a commercially available NTCC-blocking drug, prevents AF-induced autonomic, electrical and structural remodelling, along with associated AF promotion.
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http://dx.doi.org/10.1093/cvr/cvz136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6873085PMC
December 2019

Exercise Frequency Determines Heart Rate Variability Gains in Older People: A Meta-Analysis and Meta-Regression.

Sports Med 2019 May;49(5):719-729

Univ Lyon, UJM-Saint-Etienne Autonomic Nervous System Research Laboratory, EA 4607 SNA-EPIS, 42023, Saint-Étienne, France.

Background: Previous studies have suggested that exercise training improves cardiac autonomic drive in young and middle-aged adults. In this study, we discuss the benefits for the elderly.

Objectives: We aimed to establish whether exercise still increases heart rate variability (HRV) beyond the age of 60 years, and to identify which training factors influence HRV gains in this population.

Methods: Interventional controlled and non-controlled studies were selected from the PubMed, Ovid, Cochrane and Google Scholar databases. Only interventional endurance training protocols involving healthy subjects aged 60 years and over, and measuring at least one heart rate global or parasympathetic index, such as the standard deviation of the normal-to-normal intervals (SDNN), total frequency power (Ptot), root mean square of successive differences between adjacent NN intervals (RMSSD), or high frequency power (HF) before and after the training intervention, were included. HRV parameters were pooled separately from short-term and 24 h recordings for analysis. Risks of bias were assessed using the Methodological Index for Non-Randomized Studies and the Cochrane risk of bias tool. A random-effects model was used to determine effect sizes (Hedges' g) for changes, and heterogeneity was assessed using Q and I statistics.

Results: Twelve studies, seven of which included a control group, including 218 and 111 subjects, respectively (mean age 69.0 ± 3.2 and 68.6 ± 2.5), were selected for meta-analysis. Including the 12 studies demonstrated homogeneous significant effect sizes for short-term (ST)-SDNN and 24 h-SDNN, with effect sizes of 0.366 (95% CI 0.185-547) and 0.442 (95% CI 0.144-0.740), respectively. Controlled study analysis demonstrated homogeneous significant effect sizes for 24 h-SDNN with g = 0.721 (95% CI 0.184-1.257), and 24 h-Ptot with g = 0.731 (95% CI 0.195-1.267). Meta-regression analyses revealed positive relationships between ST-SDNN effect sizes and training frequency ([Formula: see text] = 0.000; [Formula: see text] = 0.000; p = 0.0462).

Conclusion: This meta-analysis demonstrates a positive effect of endurance-type exercise on autonomic regulation in older adults. However, the selected studies expressed some risks of bias. We conclude that chronic endurance exercise leads to HRV improvements in a linear frequency-response relationship, encouraging the promotion of high-frequency training programmes in older adults.
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http://dx.doi.org/10.1007/s40279-019-01097-7DOI Listing
May 2019

Exclusion of Intra-Atrial Thrombus Diagnosis Using D-Dimer Assay Before Catheter Ablation of Atrial Fibrillation.

JACC Clin Electrophysiol 2019 02 1;5(2):223-230. Epub 2018 Nov 1.

CHU Rouen, Rouen, France.

Objectives: This study hypothesized that the association of D-dimer blood level and several clinical items in a new risk score could predict the absence of atrial thrombus.

Background: Symptomatic and drug resistant atrial fibrillation (AF) can be treated by catheter ablation. The procedure-related risk of thromboembolism is limited by the pre-operative use of transesophageal echocardiography (TEE) to detect atrial thrombi.

Methods: Patients admitted for catheter ablation of AF (n = 2,494) were prospectively included in a multicenter study. TEE was systematically performed before the procedure to search for atrial thrombus (primary endpoint). D-dimer level, CHADS score, left ventricular ejection fraction, pre-operative anticoagulation regimen, and medical history were collected. A logistic regression model was used to identify factors associated with the presence of atrial thrombus (hypertension, history of stroke, heart failure, D-dimer level >270 ng/ml). These factors were aggregated in a new score called atrial thrombus exclusion (ATE).

Results: The incidence of atrial thrombus was 1.92%. CHADS score and D-dimer level were significantly associated with atrial thrombus (p < 0.0001 and p < 0.0001, respectively). A zero CHADS score failed to exclude all atrial thrombi (5 false negatives; sensitivity: 89.58%, specificity: 52.2%). No false negative was found with a zero ATE score, which had a specificity of 37% and a higher sensitivity (100%) than the CHADS score (p < 0.031) to predict the absence of intra-atrial thrombi on TEE. Conversely, the positive predictive value was poor, and the ATE score should not be used to conclude a positive diagnosis of thrombus.

Conclusions: An ATE score of zero was strongly associated with the absence of atrial thrombus. This new score could be useful to rule out a diagnosis of atrial thrombus before catheter ablation of AF.
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http://dx.doi.org/10.1016/j.jacep.2018.09.009DOI Listing
February 2019

Impact of body mass index on the outcome of catheter ablation of atrial fibrillation.

Heart 2019 02 2;105(3):244-250. Epub 2018 Oct 2.

Department of Cardiology, Cardiovascular Institute, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain.

Objectives: The association between obesity and atrial fibrillation (AF) is well-established. We aimed to evaluate the impact of index body mass index (BMI) on AF recurrence at 12 months following catheter ablation using propensity-weighted analysis. In addition, periprocedural complications and fluoroscopy details were examined to assess overall safety in relationship to increasing BMI ranges.

Methods: Baseline, periprocedural and follow-up data were collected on consecutive patients scheduled for AF ablation. There were no specific exclusion criteria. Patients were categorised according to baseline BMI in order to assess the outcomes for each category.

Results: Among 3333 patients, 728 (21.8%) were classified as normal (BMI <25.0 kg/m), 1537 (46.1%) as overweight (BMI 25.5-29.0 kg/m) and 1068 (32.0%) as obese (BMI ≥30.0 kg/m). Procedural duration and radiation dose were higher for overweight and obese patients compared with those with a normal BMI (p=0.002 and p<0.001, respectively). An index BMI ≥30 kg/m led to a 1.2-fold increased likelihood of experiencing recurrent AF at 12-months follow-up as compared with overweight patients (HR 1.223; 95% CI 1.047 to 1.429; p=0.011), while no significant correlation was found between overweight and normal BMI groups (HR 0.954; 95% CI 0.798 to 1.140; p=0.605) and obese versus normal BMI (HR 1.16; 95% CI 0.965 to 1.412; p=0.112).

Conclusions: Patients with a baseline BMI ≥30 kg/m have a higher recurrence rate of AF following catheter ablation and therefore lifestyle modification to target obesity preprocedure should be considered in these patients.
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http://dx.doi.org/10.1136/heartjnl-2018-313490DOI Listing
February 2019

Device complications with addition of defibrillation to cardiac resynchronisation therapy for primary prevention.

Heart 2018 09 14;104(18):1529-1535. Epub 2018 Mar 14.

Cardiovascular Epidemiology, Paris Cardiovascular Research Center, Paris, France.

Objective: In patients indicated for cardiac resynchronisation therapy (CRT), the choice between a CRT-pacemaker (CRT-P) versus defibrillator (CRT-D) remains controversial and indications in this setting have not been well delineated. Apart from inappropriate therapies, which are inherent to the presence of a defibrillator, whether adding defibrillator to CRT in the primary prevention setting impacts risk of other acute and late device-related complications has not been well studied and may bear relevance for device selection.

Methods: Observational multicentre European cohort study of 3008 consecutive patients with ischaemic or non-ischaemic dilated cardiomyopathy and no history of sustained ventricular arrhythmias, undergoing CRT implantation with (CRT-D, n=1785) or without (CRT-P, n=1223) defibrillator. Using propensity score and competing risk analyses, we assessed the risk of significant device-related complications requiring surgical reintervention. Inappropriate shocks were not considered except those due to lead malfunction requiring lead revision.

Results: Acute complications occurred in 148 patients (4.9%), without significant difference between groups, even after considering potential confounders (OR=1.20, 95% CI 0.72 to 2.00, p=0.47). During a mean follow-up of 41.4±29 months, late complications occurred in 475 patients, giving an annual incidence rate of 26 (95% CI 9 to 43) and 15 (95% CI 6 to 24) per 1000 patient-years in CRT-D and CRT-P patients, respectively. CRT-D was independently associated with increased occurrence of late complications (HR=1.68, 95% CI 1.27 to 2.23, p=0.001). In particular, when compared with CRT-P, CRT-D was associated with an increased risk of device-related infection (HR 2.10, 95% CI 1.18 to 3.45, p=0.004). Acute complications did not predict overall late complications, but predicted device-related infection (HR 2.85, 95% CI 1.71 to 4.56, p<0.001).

Conclusions: Compared with CRT-P, CRT-D is associated with a similar risk of periprocedural complications but increased risk of long-term complications, mainly infection. This needs to be considered in the decision of implanting CRT with or without a defibrillator.
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http://dx.doi.org/10.1136/heartjnl-2017-312546DOI Listing
September 2018

Comparison of prevalence and management of left atrial appendage thrombi under old and new anticoagulants prior to left atrial catheter ablation.

Am Heart J 2017 Nov 2;193:8-15. Epub 2017 Aug 2.

Division of Cardiology, Jean Monnet University (ADC, CD, JBG, AG, RP, CRB, and KI), Saint-Etienne, France.

Background: The prevalence and management of left atrial appendage (LAA) thrombi associated with new anticoagulants remain to be elucidated, especially prior to atrial fibrillation (AFib) ablation. This study sought to (1) compare the prevalence of LAA thrombi and/or severe LAA contrast under vitamin K antagonist (VKA) agents and novel oral anticoagulants (NOACs), (2) evaluate the rate of LAA thrombus resolution after anticoagulation modification, and (3) determine the predictive factors of LAA thrombi and severe LAA contrast in patients prior to LA AFib ablation.

Methods: Between January 2013 and March 2016, 576 consecutive patients referred for AFib ablation were included, and the prevalence of transesophageal echocardiography-detected thrombi was similar under NOACs (2.1%) and VKA agents (2.6%).

Results: Thrombus resolution was obtained in 50% of cases following anticoagulation modification. Through multivariate exact logistic regression analysis with relevant clinical and echocardiographic features, age (P<.001), LAA hypocontractility (P<.001), and left ventricular ejection fraction (P=.007) were found to be independently associated with the occurrence of LAA thrombus. The relevant factors independently associated with LAA thrombus or severe contrast were LAA hypocontractility (P<.001) and age (P<.001).

Conclusions: The prevalence of transesophageal echocardiography-detected thrombi in patients referred for AFib ablation is similar under NOACs (2.1%) and VKA agents (2.6%). Under VKA therapy with 3-4 international normalized ratio, 50% of thrombi dissolved. Independent predictive factors of procedure contraindication included age, LAA hypocontractility, and left ventricular ejection fraction.
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http://dx.doi.org/10.1016/j.ahj.2017.07.016DOI Listing
November 2017

Editorial commentary: Leadless pacemaker: A pacemaker revolution or a simply new alternative solution?

Authors:
Antoine Da Costa

Trends Cardiovasc Med 2018 02 23;28(2):142-143. Epub 2017 Aug 23.

Division of Cardiology, Jean Monnet University (ADC), Saint-Etienne, France. Electronic address:

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http://dx.doi.org/10.1016/j.tcm.2017.08.009DOI Listing
February 2018

Risk stratification of cardiovascular and heart failure hospitalizations using integrated device diagnostics in patients with a cardiac resynchronization therapy defibrillator.

Europace 2018 05;20(5):e69-e77

University of Bologna, S. Orsola-Malpighi University Hospital, Via Albertoni, 15, Bologna, Italy.

Aims: Cardiac resynchronization therapy defibrillators (CRT-D) are able to monitor various parameters that may be combined by an automatic algorithm to provide a heart failure risk status (HFRS). We sought to validate the HFRS for stratifying patient risk, evaluate its association with heart failure (HF) symptoms, and investigate its utility for triage of automatic alerts.

Methods And Results: Data from 722 patients included in the MORE-CARE trial were analysed in a post hoc analysis. A high HFRS was associated with a significantly increased risk of admission over the next 30 days with a relative risk for cardiovascular hospitalization (CVH) of 4.5 (95% CI: 3.1-6.6, P < 0.001), of HF hospitalization of 6.3 (95% CI: 3.9-10.2, P < 0.001) and of non-HF related CVH of 3.5 (95% CI: 2.0-6.9, P < 0.001). The negative predictive value of low or medium HFRS for these admissions was ≥98%. A high HFRS was associated with an increased risk of HF symptoms. Of all the automatic remote monitoring alerts generated during the study, only 10% had a high HFRS.

Conclusion: The HFRS is able to risk-stratify CRT-D patients, which is potentially useful for managing automatic remote monitoring alerts, by focusing attention on the minority of high-risk patients.

Clinical Trial Registration: The trial was registered at www.clinicaltrials.gov under number NCT00885677.
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http://dx.doi.org/10.1093/europace/eux206DOI Listing
May 2018

Atrial fibrillation in cancer patients: Hindsight, insight and foresight.

Int J Cardiol 2017 Aug 6;240:196-202. Epub 2017 Apr 6.

Department of Vascular and Therapeutic Medicine, University Hospital of Saint-Etienne, France; INSERM, CIC1408, Saint-Etienne, France; INSERM, U1059, Vascular Dysfunction and Homeostasis, Saint-Etienne, France.

An increase of atrial fibrillation (AF) incidence in cancer patients has recently been pointed out, with complex interrelationships between these two entities on top of surgery factors. Most of present knowledge comes from retrospective studies or data from registries but the underlying mechanisms of the association between atrial fibrillation and cancer are still unclear. An increased risk of AF in cancer patients could represent a major public health problem although scarce information is available for the challenging management of such patients with distinctive features, especially in terms of antithrombotic therapy. Elaborate evidence-based approaches are thus required. This review provides an insight into AF among cancer patients through an overview of the underlying mechanisms, epidemiology evidence and future therapeutic challenges.
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http://dx.doi.org/10.1016/j.ijcard.2017.03.132DOI Listing
August 2017

Substantial superiority of Niobe ES over Niobe II system in remote-controlled magnetic pulmonary vein isolation.

Int J Cardiol 2017 Mar 22;230:319-323. Epub 2016 Dec 22.

Division of Cardiology, Jean Monnet University, Saint-Etienne, France.

Background: Catheter ablation of atrial fibrillation (AFib) primarily relies upon pulmonary vein isolation (PVI), but such procedures are associated with significant X-ray exposure. The newer Epoch system has been developed so as to enable more precise magnetic navigation whilst limiting X-ray exposure.

Objectives: This study was aimed at quantifying both exposure time and X-ray reduction with the newer Epoch system compared to Niobe II during AFib ablation procedures.

Methods: From November 2011 to November 2013, our last 92 consecutive patients treated with the Niobe ES (Epoch Solution; 4th generation magnetic navigation technology) system were compared with the first 92 consecutive patients treated using the Niobe II system (3rd generation magnetic navigation technology) for symptomatic drug-refractory AFib.

Results: Mean patient age was 59±11years (20% female), and the study population was affected by either symptomatic paroxysmal (65.2%) or persistent (34.8%) AFib. Median procedure time was 2±0.5h and median total X-ray exposure 12.3±6.4min. Procedure time (1.9±0.4 vs. 2.7±1h, p<0.0001) and X-ray duration (12±4 vs. 15±7min, p=0.001) were significantly lower with Niobe ES than with the Niobe II system. X-ray ablation exposure time was also significantly lower with the Niobe ES system than with the Niobe II system (2.9±2 vs. 4±3.5min; p=0.01). Through multivariate analysis, the only predictive factors influencing both procedure duration and X-ray exposure were found to be the Niobe ES system use and LA size.

Conclusions: Our study was the first to demonstrate that the new Niobe ES magnetic robotic system substantially reduced overall operating, fluoroscopy, and ablation times during AFib ablation procedure.
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http://dx.doi.org/10.1016/j.ijcard.2016.12.115DOI Listing
March 2017

Transcatheter leadless cardiac pacing: The new alternative solution.

Int J Cardiol 2017 Jan 9;227:122-126. Epub 2016 Nov 9.

Division of Cardiology, Jean Monnet University (ADC, AA, CRB, LA, ZA, JBG, AG, and KI), Saint-Etienne, France.

Introduction: A lack of information about the feasibility and safety of leadless pacemaker (LPMs) exists in a fragile population of patients with limited venous anatomy access or conventional pacemaker (PM) contraindication. Accordingly, the goal of this prospective observational study was to report our experience with this new leadless technology in a subset of patients with contraindication or limited venous access.

Methods And Results: Between May 2015 and July 2016, 14 patients were consecutively included. The indications for initial PM implantation were atrioventricular (AV) block in 10/14 patients (71%), bradyarrhythmia in one (7%), and uncontrolled atrial fibrillation (AFib) requiring AV-node ablation in three (21.5%). AFib was observed in 9 of the 14 patients (64.3%) and 3 were completely dependent with no escape rhythm (21.5%). Normal access pathways via the right or left subclavian veins were occluded due to previous PM implantations and revisions in 4 patients (28.6%) and total vena cava occlusion in 3 (21.4%). End-stage renal disease with hemodialysis was present in 8 (57%) with either local-device infections or presence of long-term implanted dialysis catheters. Evidence of previous bilaterally-infected pectoral tissue was present in 3 patients (21.5%). All procedures were successful (100%) and electrical parameters remained stable over time. No direct pacemaker-related adverse events were reported, including mechanical complications, except for one ventricular fibrillation one day post-implantation under very specific conditions.

Conclusion: This series demonstrated very stable performance and reassuring safety results during mid-term follow-up in a very fragile population requiring a PM. The Micra LPM constitutes an excellent alternative to the epicardial surgical approach in this very fragile population.
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http://dx.doi.org/10.1016/j.ijcard.2016.11.196DOI Listing
January 2017