Publications by authors named "Bruno Degand"

23 Publications

  • Page 1 of 1

Virtual Reality for Sedation During Atrial Fibrillation Ablation in Clinical Practice: Observational Study.

J Med Internet Res 2021 05 27;23(5):e26349. Epub 2021 May 27.

Department of Anesthesia and Critical Care, University Hospital of Poitiers, Poitiers, France.

Background: Connected devices are dramatically changing many aspects in health care. One such device, the virtual reality (VR) headset, has recently been shown to improve analgesia in a small sample of patients undergoing transcatheter aortic valve implantation.

Objective: We aimed to investigate the feasibility and effectiveness of VR in patients undergoing atrial fibrillation (AF) ablation under conscious sedation.

Methods: All patients who underwent an AF ablation with VR from March to May 2020 were included. Patients were compared to a consecutive cohort of patients who underwent AF ablation in the 3 months prior to the study. Primary efficacy was assessed by using a visual analog scale, summarizing the overall pain experienced during the ablation.

Results: The AF cryoablation procedure with VR was performed for 48 patients (mean age 63.0, SD 10.9 years; n=16, 33.3% females). No patient refused to use the device, although 14.6% (n=7) terminated the VR session prematurely. Preparation of the VR headset took on average 78 (SD 13) seconds. Compared to the control group, the mean perceived pain, assessed with the visual analog scale, was lower in the VR group (3.5 [SD 1.5] vs 4.3 [SD 1.6]; P=.004), and comfort was higher in the VR group (7.5 [SD 1.6] vs 6.8 [SD 1.7]; P=.03). On the other hand, morphine consumption was not different between the groups. Lastly, complications, as well as procedure and fluoroscopy duration, were not different between the two groups.

Conclusions: We found that VR was associated with a reduction in the perception of pain in patients undergoing AF ablation under conscious sedation. Our findings demonstrate that VR can be easily incorporated into the standard ablation workflow.
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http://dx.doi.org/10.2196/26349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193475PMC
May 2021

Impact of the atrial lead pacing site regarding atrial fibrillation onset in patients with sinus node dysfunction.

Int J Cardiol 2021 06 1;332:85-86. Epub 2021 Apr 1.

University Hospital of Poitiers, Cardiology Department, 2 rue de la Milétrie, F-86021 Poitiers, France; Univ Poitiers, Faculté de Médecine et Pharmacie, F-86021 Poitiers, France. Electronic address:

Symptomatic sinus node disease (SND) most frequently requires the implantation of a dual chamber pacemaker of which the right atrial lead is generally implanted in the right atrial appendage (RAA) or the lateral wall (LW).The aim of this retrospective study was to evaluate the impact of the right atrial lead pacing site regarding the onset of AF in patients with SND. RESULTS: 126 patients were included (53% males; 76 yo). 64 (51%) patients were implanted in the RAA and 62 (49%) in the LW. The two groups were not different in terms of CHADS-VASc score and indexed left atrial volume. Forty-eight months after implantation, AF occurred in 17 (26.6%) of the RAA group and 6 (9.7%) in the lateral group. In the multivariate models, RAA site was the only factor associated with AF onset, with an Hazard Ratio of 2.5 (95%CI 1.1; 5.7; P=0.03). CONCLUSION: In our study, RAA pacing was associated with 2.5 higher risk of AF onset in patients with SND. Further larger randomized studies are needed to confirm these findings.
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http://dx.doi.org/10.1016/j.ijcard.2021.03.074DOI Listing
June 2021

[Screening and diagnosis of atrial fibrillation].

Rev Prat 2020 Oct;70(8):899-902

Unité de rythmologie, centre cardio-vasculaire, CHU de Poitiers, Poitiers, France.

Screening and diagnosis of atrial fibrillation. Screening for atrial fibrillation (AF) is crucial as this arrhythmia is asymptomatic in a third of patients and 5% of patients present a stroke as the first manifestation of their AF. The European Society of Cardiology recommends opportunistic screening of AF in patients over 65 years of age and systematically in patients over 75 years of age. The simplest way is pulse taking, but the number of connected devices for AF screening allows to multiply the frequency of screening and thus increase sensitivity, with another advantage of a digitalized transmission of the tracing. However many questions remain. No scientific evidence has demonstrated a benefit for AF screening. We do not know what duration and frequency of screening is relevant. The burden of AF which increases thromboembolic risk is not known. What population should be screened and how to consider subclinical AF? We will obtain answers to our questions in the coming years thanks to the results of the various studies in progress.
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October 2020

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

Europace 2021 01;23(1):73-81

Department of Cardiology, General Hospital of Cannes, 06150 Cannes, 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

Hypnosis Versus Placebo During Atrial Flutter Ablation: The PAINLESS Study: A Randomized Controlled Trial.

JACC Clin Electrophysiol 2020 11 12;6(12):1551-1560. Epub 2020 Aug 12.

Centre Hospitalier Universitaire (CHU) Poitiers, Cardiology Department, Poitiers, France.

Objectives: The aim of this study was to assess the superiority of hypnosis versus placebo on pain perception and morphine consumption during typical atrial flutter (AFL) ablation.

Background: AFL ablation commonly requires intravenous opioid for analgesia, which can be associated with adverse outcomes. Hypnosis is an alternative technique with rising interest, but robust data in electrophysiological procedures are lacking.

Methods: This single center, randomized controlled trial compared hypnosis and placebo during AFl ablation. In addition to the randomized intervention, all patients were treated according to the institution's standard of care analgesia protocol (administration of 1 mg of intravenous morphine in case of self-reported pain ≥5 on an 11-point numeric rating scale or on demand). The primary endpoint was perceived pain quantified by patients using a visual analog scale.

Results: Between October 2017 and September 2019, 113 patients (mean age 70 ± 12 years, 21% women) were randomized to hypnosis (n = 56) or placebo (n = 57). Mean pain score was 4.0 ± 2.2 in the hypnosis group versus 5.5 ± 1.8 in the placebo group (p < 0.001). Pain perception, assessed every 5 min during the whole procedure, was consistently lower in the hypnosis group. Patients' sedation scores were also better in the hypnosis group than in the placebo group (8.3 ± 2.2 vs. 5.4 ± 2.5; p < 0.001). Finally, morphine requirements were significantly lower in the hypnosis group (1.3 ± 1.3 mg) compared with the placebo group (3.6 ± 1.8 mg; p < 0.001).

Conclusions: In this first randomized trial, hypnosis during AFL ablation was superior to placebo for alleviating pain and reducing morphine consumption.
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http://dx.doi.org/10.1016/j.jacep.2020.05.028DOI Listing
November 2020

Non-invasive hemodynamic determination of patient-specific optimal pacing mode in cardiac resynchronization therapy.

J Interv Card Electrophysiol 2021 Nov 30;62(2):347-356. Epub 2020 Oct 30.

Department of Electrophysiology and Pacing, Centre Médico-Chirurgical Ambroise Paré, 27 Boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France.

Purpose: Cardiac resynchronization therapy (CRT) devices have multiple programmable pacing parameters. The purpose of this study was to determine the best pacing mode, i.e., associated with the greatest acute hemodynamic response, in each patient.

Methods: Patients in sinus rhythm and intact atrioventricular conduction were included within 3 months of implantation of devices featuring SyncAV and multipoint pacing (MPP) algorithms. The effect of nominal biventricular pacing using the latest activated electrode (BiV-Late), optimized atrioventricular delay (AVD), nominal and optimized SyncAV, and anatomical MPP was determined by non-invasive measurement of systolic blood pressure (SBP). CRT response was defined as SBP increase > 10% relative to baseline.

Results: Thirty patients with left bundle branch block (LBBB) were included. BiV-Late increased SBP compared to intrinsic rhythm (128 ± 21 mmHg vs. 121 ± 22 mmHg, p = 0.0002). The best pacing mode further increased SBP to 140 ± 19 mmHg (p < 0.0001 vs. BiV-Late). The proportion of CRT responders increased from 40% with BiV-Late to 80% with the best pacing mode (p = 0.0005). Compared to BiV-Late, optimized AVD and optimized SyncAV increased SBP (to 134 ± 21 mmHg, p = 0.004, and 133 ± 20 mmHg, p = 0.0003, respectively), but nominal SyncAV and MPP did not. The best pacing mode was variable between patients and was different from nominal BiV-Late in 28 (93%) patients. Optimized AVD was the most frequent best mode, in 14 (47%) patients.

Conclusion: In patients with LBBB, the best pacing mode was patient-specific and doubled the magnitude of acute hemodynamic response and the proportion of acute CRT responders compared to nominal BiV-Late pacing.

Trial Registration: ClinicalTrials.gov : NCT03779802.
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http://dx.doi.org/10.1007/s10840-020-00908-6DOI Listing
November 2021

Prognostic value of Charlson Comorbidity Index in the elderly with a cardioverter defibrillator implantation.

Int J Cardiol 2020 09 26;314:64-69. Epub 2020 Mar 26.

CHU Poitiers, Service de Cardiologie, 2 rue de la Milétrie, F-86021 Poitiers, France; Univ Poitiers, Faculté de Médecine et Pharmacie, F-86021 Poitiers, France; INSERM CIC 1402, CHU Poitiers, 2 rue de la Milétrie, F-86021 Poitiers, France. Electronic address:

Background: Elderly patients are often underrepresented in implantable cardioverter defibrillator (ICD) trials, and ICD implantation in patients ≥75 years consequently remains controversial. We aimed to evaluate mortality, appropriate ICD therapy rates and survival gain in an elderly population after risk stratification according to the Charlson Comorbidity Index (CCI).

Methods: This monocentric retrospective study included elderly ICD patients ≥75 years. They were subdivided according to their CCI score into 3 categories (0-1, 2-3 or ≥4 points). Elderly patients were matched 1:2 with younger control ICD patients on gender, type of prevention (primary or secondary) and type of device (associated cardiac resynchronization therapy or not).

Results: Between January 2009 and July 2017, 121 elderly patients (mean age 78 ± 3; 83% male) matched with 242 controls (mean age 66 ± 5) were included. At 5 year follow-up after ICD implantation, overall survival was 78%, 57%, and 29% (P = 0.002) in the elderly with a CCI score of 0-1, 2-3 and ≥4 respectively, and 72% in controls. There was no significant difference regarding ICD appropriate therapy between the 3 subgroups despite a trend towards lower rates of therapy in CCI ≥ 4 points patients (34.2%, 39.7% and 22.8% respectively; P = 0.45). Median potential survival gain after an appropriate therapy was >5, 4.7 and 1.4 years, with a CCI score of 0-1, 2-3 and ≥4 respectively (P = 0.01).

Conclusion: Elderly patients with CCI score ≥ 4 had the lowest survival after ICD implantation and little survival gain in case of appropriate defibrillator therapy. More than age alone, the burden of comorbidities assessed by the CCI could be helpful to better select elderly patients for ICD implantation.
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http://dx.doi.org/10.1016/j.ijcard.2020.03.060DOI Listing
September 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

Baroreflex sensitivity assessed with the sequence method is associated with ventricular arrhythmias in patients implanted with a defibrillator for the primary prevention of sudden cardiac death.

Arch Cardiovasc Dis 2019 Apr 19;112(4):270-277. Epub 2019 Jan 19.

CHU Poitiers, CIC 1402, 86021 Poitiers, France; Faculté de médecine et pharmacie, université Poitiers, 86021 Poitiers, France.

Background: Left ventricular ejection fraction lacks accuracy in predicting sudden cardiac death, resulting in unnecessary implantation of cardioverter defibrillators for the primary prevention of sudden cardiac death. Baroreflex sensitivity could help to stratify patients at risk of ventricular arrhythmia.

Aim: To assess the association between cardiac baroreflex sensitivity and ventricular arrhythmias in patients implanted with an implantable cardioverter defibrillator for the primary prevention of sudden cardiac death after myocardial infarction.

Methods: This case-control single-centre study took place between 2015 and 2016. Cases (n=10) had experienced ventricular arrhythmias treated by the implantable cardioverter defibrillator in the previous 3 years; controls (n=22) had no arrhythmia during the same period. Baroreflex sensitivity was assessed using the temporal sequence method (mean slope) and cross-spectral analysis (low-frequency gain and high-frequency gain).

Results: The mean age was 65 years; 94% of the patients were men. 24-hour Holter electrocardiogram autonomous nervous system variables, left ventricular ejection fraction and N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) concentration did not differ between cases and controls. The mean slope was lower in cases than in controls (8 vs. 15ms/mmHg [P=0.009] in the supine position; 7 vs. 12ms/mmHg [P=0.038] in the standing position). The mean slope in the supine position was still significantly different between groups after adjustment for age, left ventricular ejection fraction and NT-proBNP (P=0.03). By comparison, low-frequency gain and high-frequency gain did not differ between groups in either the supine or the standing position.

Conclusion: Patients with ventricular arrhythmias had a lower mean slope compared with those who were free of arrhythmia. A prospective study is needed to confirm this association.
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http://dx.doi.org/10.1016/j.acvd.2018.11.009DOI Listing
April 2019

Occurrence of significant long PR intervals in patients implanted for sinus node dysfunction and monitored with SafeR™: The PRECISE study.

Arch Cardiovasc Dis 2019 Mar 26;112(3):153-161. Epub 2018 Dec 26.

Henri Mondor hospital, 94101 Créteil, France.

Background: Long PR intervals may increase cardiovascular complications, including atrial fibrillation. In pacemakers, the SafeR™ mode monitors PR intervals, switching from AAI to DDD when criteria for atrioventricular block are met.

Aims: The PRECISE study evaluated the incidence and predictors of long PR intervals and their association with incident atrial fibrillation after 1 year in patients implanted for sinus node dysfunction and free from significant conduction disorders at baseline.

Methods: This French, prospective, multicentre, observational trial enrolled patients implanted with a REPLY™ dual-chamber pacemaker. Pacemaker memory recorded long PR intervals (defined as first-degree atrioventricular block mode switches occurring after six consecutive PR/AR intervals≥350/450ms) and atrial fibrillation incidence (fallback mode switch>1minute/day). Predictors were identified from baseline variables (age, sex, AR and PR intervals, atrial rhythm disorder and medication) using logistic regression.

Results: Of 291 patients with sinus node dysfunction enrolled, 214 were free from significant conduction disorders at baseline (mean age 79±8 years; 44% men; PR/AR intervals<350/450ms). After 1 year, long PR intervals had occurred in 116 patients (54%) and atrial fibrillation in 63 patients (30%). Amiodarone was the only independent predictor of long PR interval occurrence (odds ratio 2.50, 95% confidence interval 1.20-5.21; P=0.014). There was a strong trend towards an association between long PR interval and atrial fibrillation incidence (odds ratio 1.86, 95% confidence interval 0.97-3.61; P=0.051).

Conclusions: Half of the patients with pure sinus node dysfunction developed long PR intervals in the year following pacemaker implantation. Amiodarone was the only independent predictor of long PR intervals. There was a strong trend towards an association between long PR intervals and incident atrial fibrillation.
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http://dx.doi.org/10.1016/j.acvd.2018.09.005DOI Listing
March 2019

Contractibility sensor signal evolution predicts cardiovascular events in patients with cardiac resynchronization therapy.

Arch Cardiovasc Dis 2019 Jan 24;112(1):22-30. Epub 2018 Dec 24.

Service de cardiologie, CHU de Poitiers, 86021 Poitiers, France.

Background: While a multicentre trial has demonstrated that the SonR™ contractibility sensor is as effective as echocardiography-guided optimization at improving response to cardiac resynchronization therapy, an association between SonR™ values and clinical endpoints has not been established.

Aims: The primary objective was to assess the predictive value of SonR™ signal evolution regarding cardiovascular events in patients implanted with a cardiac resynchronization therapy device. The secondary objective was to evaluate whether SonR™ signal evolution was associated with cardiovascular death.

Methods: All patients with a SonR™ system implanted between 2012 and 2016 were included in this retrospective study. SonR™ signal evolution was calculated over the first 6 months after implantation: ([month 6 value-month 1 value]/month 1 value)*100. The primary endpoint (cardiovascular events) was a composite of cardiovascular death, hospitalization for acute heart failure or ventricular arrhythmia.

Results: Seventy-four patients (median age 67 years; 81% men) were followed up over a median 20 (13; 29) months. Cumulative incidence function showed that SonR™ signal evolution was predictive of cardiovascular events (threshold<10.70%; P=0.023) and predictive of cardiovascular death (P=0.0018). After multivariable analysis, SonR™ signal evolution was independently associated with the onset of cardiovascular events (hazard ratio: 4.03, 95% confidence interval: 1.31-12.43; P=0.015), even after adjustment for left bundle branch block and chronic kidney disease.

Conclusions: In this first study publishing data on SonR™ signals in a real-life setting, SonR™ signal evolution over the first 6 months after cardiac resynchronization implantation was an independent predictor of cardiovascular events at follow-up. This variable could be useful to identify patients at higher risk of further adverse events after cardiac resynchronization implantation.
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http://dx.doi.org/10.1016/j.acvd.2018.07.003DOI Listing
January 2019

Twenty-four-hour ambulatory ECG monitoring relevancy in myotonic dystrophy type 1 follow-up: Prognostic value and heart rate variability evolution.

Ann Noninvasive Electrocardiol 2019 01 12;24(1):e12587. Epub 2018 Aug 12.

Department of Cardiology, CHU Poitiers, Poitiers, France.

Background: Patient prognosis in type 1 myotonic dystrophy (DM1) is very poor. Annual 24-hour holter ECG monitoring is recommended but its relevance is debated. Main objective was to determine whether holter ECG parameters could predict global death in DM1 patients and secondarily to assess whether they could predict cardiovascular events and sudden cardiac death, to compare DM1 patients and healthy controls, and to assess their evolution in DM1 over a 5-year period.

Methods: This retrospective study included genetically confirmed DM1. Primary endpoint was global death. Secondary endpoints were labeled "sudden cardiac death" which was a composite of sudden cardiac death, aborted sudden cardiac death, implantable cardioverter defibrillator therapy, sustained ventricular tachycardia, atrioventricular block grade 3, pause >3 s; and "cardiovascular events" which was a composite of all-cause mortality, pacemaker or cardioverter defibrillator implantation, sustained ventricular tachycardia, supraventricular tachycardia, hospitalization for acute cardiac cause and heart failure.

Results: Forty-seven patients (22 women, 40 ± 13 years old) were included. Three (7%) DM1 patients died, 9 (19%) experienced "sudden cardiac death" endpoint and 21 (45%) experienced "cardiovascular event" endpoint during mean follow-up of 95 ± 22 months. None of holter ECG parameters were discriminant to predict death or secondary endpoints. Compared to healthy controls, DM1 patients had higher SDNN and LF/HF ratio. Finally, heart rate variability parameters remained stable over a mean interval of 61 ± 15 months excepting pNN50 which decreased significantly.

Conclusion: Results suggest that annually-repeated holter ECG in DM1 is not useful for stratifying risk of sudden death and cardiovascular outcomes.
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http://dx.doi.org/10.1111/anec.12587DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6931664PMC
January 2019

Right ventricular longitudinal strain: a tool for diagnosis and prognosis in light-chain amyloidosis.

Amyloid 2018 Mar 20;25(1):18-25. Epub 2017 Dec 20.

a Cardiology Department , CHU de Poitiers , Poitiers , France.

Objectives: Light-chain (AL) amyloidosis can lead to an infiltrative cardiomyopathy with increased wall thickness (IWT) of very poor prognosis. Our primary aim was to analyse the right ventricle (RV) in patients with IWT to discriminate AL amyloidosis from IWT due to hypertrophic cardiomyopathy (HCM) or to arterial hypertension (HTN). Our secondary aim was to assess if RV dysfunction predicts overall mortality in cardiac AL amyloidosis.

Methods: We retrospectively and consecutively compared clinical, biological and echocardiographic data of 315 patients with IWT: 105 biopsy-proven AL amyloidosis patients, 105 patients with HCM and 105 patients with HTN. The prognostic value of these parameters was analysed in the AL amyloidosis group.

Results: Free-wall right ventricular longitudinal strain (FWRVLS) worse than -21.2% discriminates AL amyloidosis [area under the curve (AUC) = 0.744)] from patients with IWT due to other aetiologies. In AL amyloidosis, FWRVLS is the strongest echocardiographic prognostic marker with AUC =0.722 and -16.5% as the optimal cut-off value, beyond which overall mortality increases significantly. It is also the only independent echocardiographic predictor of overall mortality (HR =1.113; 95%CI 1.029-1.204; p = .007), even when adjusted to the Mayo stage and global left ventricular longitudinal strain.

Conclusions: FWRVLS should be considered in the diagnostic and prognostic workup in light-chain amyloidosis.
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http://dx.doi.org/10.1080/13506129.2017.1417121DOI Listing
March 2018

Left ventricular longitudinal strain impairment predicts cardiovascular events in asymptomatic type 1 myotonic dystrophy.

Int J Cardiol 2017 Sep 19;243:424-430. Epub 2017 May 19.

Assistance Publique-Hôpitaux de Paris, Hopital Bichat, Service de Cardiologie, F-75018 Paris, France.

Background: Type 1 myotonic dystrophy (DM1) patients' prognosis is very poor. Up until now, only a few prognostic factors for cardiovascular events have been identified, and they are predictive of end-stage disease. The aim was to assess the prognostic value of global longitudinal strain (GLS) for cardiovascular events in asymptomatic DM1 patients.

Methods: DM1 patients were included between 2011 and 2015 and followed up until January 2016. Patients underwent a transthoracic echocardiography at inclusion. The primary endpoint was a composite of all-cause mortality, type 2 Mobitz 2 and type 3 atrioventricular block, symptomatic sino-atrial block, HV interval≥70ms at invasive electrophysiology exploration, left ventricular ejection fraction (LVEF) ≤45% and newly developed atrial fibrillation.

Results: Forty-six patients (25 males, mean age 40years old) were included. The primary outcome was reached in 14 patients with a mean follow-up of 38months. GLS of patients who reached the primary endpoint was significantly impaired as compared to those who did not (-15.1 [-16.7; -12.7] vs. -18.2 [-19.2; -16.7] respectively; P=0.001). According to ROC curve analysis, probability of primary outcome occurrence was significantly greater in patients with GLS values≥-17.2% (P=0.001). On multivariate analysis, PR electrocardiogram interval and GLS remained significantly and independently associated with the primary endpoint [hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.01-1.04, P=0.006 for PR interval; HR 1.4, 95% CI 1.1-1.7, P=0.002 for GLS] while LVEF alone was not.

Conclusion: Left ventricular GLS is a powerful marker to predict cardiovascular events in asymptomatic DM1 patients, independently of LVEF.
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http://dx.doi.org/10.1016/j.ijcard.2017.05.061DOI Listing
September 2017

Subcutaneous cardioverter defibrillator has longer time to therapy but is less cardiotoxic than transvenous cardioverter defibrillator. Study carried out in a preclinical porcine model.

Europace 2018 05;20(5):873-879

CHU Poitiers, Service de Cardiologie, 2 rue de la Milétrie, Poitiers 86021, France.

Aims: Totally subcutaneous implantable cardioverter defibrillator (S-ICD) delivers higher shock energy and can have longer time to therapy compared to transvenous implantable cardioverter defibrillator (T-ICD). Aim of the study was to compare time to therapy and to investigate cardiac, cerebral and systemic injuries of S-ICD and T-ICD shocks delivered after ventricular fibrillation (VF) induction.

Methods And Results: Fourteen pigs were randomly implanted with a S-ICD (n = 7) or a T-ICD (n = 7). Five VF episodes were induced in each pig. For each VF episode, up to two shocks could be delivered by the T-ICD or the S-ICD to terminate the arrhythmia. Cardiac, systemic, and cerebral toxicity were monitored. Mean time to therapy was longer in the S-ICD group compared to the T-ICD group (19[18; 23] s vs. 9 [7; 10] s; P = 0.001, respectively). High-sensitivity troponin T levels were significantly higher in the T-ICD group from 1 to 24 h after the procedure (P ≤ 0.02). Creatine phosphokinase activity levels were significantly higher in the S-ICD group, at 3, 6, and 24 h after the procedure (P ≤ 0.05). Lactate levels were not significantly different between groups. S100 protein level was similar in both groups at 1 h after the procedure and then decreased in the T-ICD group compared to the S-ICD group (P = 0.04).

Conclusions: Time to therapy in S-ICD was twice as long as for T-ICD, but didn't induce relevant brain injury. Conversely, S-ICD shocks were less cardiotoxic than T-ICD shocks.
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http://dx.doi.org/10.1093/europace/eux074DOI Listing
May 2018

Apical left ventricular myocardial dysfunction is an early feature of cardiac involvement in myotonic dystrophy type 1.

Echocardiography 2017 Feb 13;34(2):184-190. Epub 2017 Feb 13.

Cardiology Service, CHU Poitiers, Poitiers, France.

Introduction: Left ventricular (LV) dysfunction is a major prognostic determinant in myotonic dystrophy type 1 (DM1). Therefore, markers of early-stage LV impairment may be useful. The aim of this study was to evaluate 2D echocardiographic LV strain in a cohort of DM1 patients with preserved left ventricular ejection fraction (LVEF) and to compare the results with matched controls.

Methods: This prospective single-center study included 33 consecutive DM1 patients between February 2014 and February 2015. Mean age was 38.2±12.9 years, and 17 (52%) were males. Exclusion criteria were LVEF <55%, QRS >120 milliseconds, history of atrial fibrillation, and presence of a pacemaker with ventricular pacing. DM1 patients were matched to healthy controls according to sex and age.

Results: DM1 patients showed significant impairment of global longitudinal strain (GLS) as compared to controls (-18.0±1.9 vs -19.1±2.4; P=.03), characterized by a marked alteration at the apex (-20.0±3.3 vs -22.7±3.1; P<.001). DM1 patients had also global radial strain impairment (20.0±9.8 vs 27.5±14.9; P=.024) compared to controls while global circumferential strain was not statistically different between groups (P=.94). Intra- and inter-observer analysis showed good reproducibility of GLS.

Conclusion: Despite preserved LVEF, DM1 patients exhibited significantly altered LV GLS, particularly at the apex, as compared with controls. The detection of impaired myocardial deformation at early stages of the disease might help to screen high-risk patients who need closer follow-up.
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http://dx.doi.org/10.1111/echo.13426DOI Listing
February 2017

[Cardiac implantable electrophysiological device (CIED) infections].

Presse Med 2017 Jan 2;46(1):120-121. Epub 2016 Nov 2.

CHU de Poitiers, service de cardiologie, 2, rue de la Milétrie, 86021 Poitiers, France.

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http://dx.doi.org/10.1016/j.lpm.2016.09.022DOI Listing
January 2017

An unusual pacemaker migration.

Indian Heart J 2016 Sep 15;68 Suppl 2:S228. Epub 2016 Jun 15.

CHU de Poitiers, Cardiac Electrophysiology Department, F86000 Poitiers, France.

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http://dx.doi.org/10.1016/j.ihj.2016.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5067814PMC
September 2016

Impact of clinical and genetic findings on the management of young patients with Brugada syndrome.

Heart Rhythm 2016 06 24;13(6):1274-82. Epub 2016 Feb 24.

CHU Nantes, Institut du Thorax, Nantes, France.

Background: Brugada syndrome (BrS) is an arrhythmogenic disease associated with sudden cardiac death (SCD) that seldom manifests or is recognized in childhood.

Objectives: The objectives of this study were to describe the clinical presentation of pediatric BrS to identify prognostic factors for risk stratification and to propose a data-based approach management.

Methods: We studied 106 patients younger than 19 years at diagnosis of BrS enrolled from 16 European hospitals.

Results: At diagnosis, BrS was spontaneous (n = 36, 34%) or drug-induced (n = 70, 66%). The mean age was 11.1 ± 5.7 years, and most patients were asymptomatic (family screening, (n = 67, 63%; incidental, n = 13, 12%), while 15 (14%) experienced syncope, 6(6%) aborted SCD or symptomatic ventricular tachycardia, and 5 (5%) other symptoms. During follow-up (median 54 months), 10 (9%) patients had life-threatening arrhythmias (LTA), including 3 (3%) deaths. Six (6%) experienced syncope and 4 (4%) supraventricular tachycardia. Fever triggered 27% of LTA events. An implantable cardioverter-defibrillator was implanted in 22 (21%), with major adverse events in 41%. Of the 11 (10%) patients treated with hydroquinidine, 8 remained asymptomatic. Genetic testing was performed in 75 (71%) patients, and SCN5A rare variants were identified in 58 (55%); 15 of 32 tested probands (47%) were genotype positive. Nine of 10 patients with LTA underwent genetic testing, and all were genotype positive, whereas the 17 SCN5A-negative patients remained asymptomatic. Spontaneous Brugada type 1 electrocardiographic (ECG) pattern (P = .005) and symptoms at diagnosis (P = .001) were predictors of LTA. Time to the first LTA event was shorter in patients with both symptoms at diagnosis and spontaneous Brugada type 1 ECG pattern (P = .006).

Conclusion: Spontaneous Brugada type 1 ECG pattern and symptoms at diagnosis are predictors of LTA events in the young affected by BrS. The management of BrS should become age-specific, and prevention of SCD may involve genetic testing and aggressive use of antipyretics and quinidine, with risk-specific consideration for the implantable cardioverter-defibrillator.
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http://dx.doi.org/10.1016/j.hrthm.2016.02.013DOI Listing
June 2016

Unmasked Brugada pattern by ajmaline challenge in patients with myotonic dystrophy type 1.

Ann Noninvasive Electrocardiol 2015 Jan 18;20(1):28-36. Epub 2014 Jun 18.

Cardiology Department, University Hospital of Poitiers, Poitiers, France; Cardiology Department, Les Franciscaines Private Hospital, Nîmes, France.

Background: Myotonic dystrophy type 1 (DM1) generates missplicing of the SCN5A gene, encoding the cardiac sodium channel (Nav 1.5). Brugada syndrome, which partly results from Nav 1.5 dysfunction and causes increased VF occurrence, can be unmasked by ajmaline. We aimed to investigate the response to ajmaline challenge in DM1 patients and its potential impact on their sudden cardiac death risk stratification.

Methods: Among 36 adult DM1 patients referred to our institution, electrophysiological study and ajmaline challenge were performed in 12 patients fulfilling the following criteria: (1) PR interval >200 ms or QRS duration >100 ms; (2) absence of complete left bundle branch block; (3) absence of permanent ventricular pacing; (4) absence of implantable cardioverter-defibrillator (ICD); (5) preserved left-ventricular ejection fraction >50%; and (6) absence of severe muscular impairment. Of note, DM1 patients with ajmaline-induced Brugada pattern (BrP) were screened for SCN5A.

Results: In all the 12 patients studied, the HV interval was <70 ms. A BrP was unmasked in three patients but none carried an SCN5A mutation. Ajmaline-induced sustained ventricular tachycardia occurred in one patient with BrP, who finally received an ICD. The other patients did not present any cardiac event during the entire follow-up (15 ± 4 months).

Conclusion: Our study is the first to describe a high prevalence of ajmaline-induced BrP in DM1 patients. The indications, the safety, and the implications of ajmaline challenge in this particular setting need to be determined by larger prospective studies.
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http://dx.doi.org/10.1111/anec.12168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6931494PMC
January 2015

Myotonic dystrophy type 1 mimics and exacerbates Brugada phenotype induced by Nav1.5 sodium channel loss-of-function mutation.

Heart Rhythm 2014 Aug 21;11(8):1393-400. Epub 2014 Apr 21.

Institut de Physiologie et de Biologie Cellulaire, ERL CNRS 7368, Université de Poitiers, France.

Background: Myotonic dystrophy type 1 (DM1), a muscular dystrophy due to CTG expansion in the DMPK gene, can cause cardiac conduction disorders and sudden death. These cardiac manifestations are similar to those observed in loss-of-function SCN5A mutations, which are also responsible for Brugada syndrome (BrS).

Objective: The purpose of this study was to investigate DM1 effects on clinical expression of a loss-of-function SCN5A mutation causing BrS.

Methods: We performed complete clinical evaluation, including ajmaline test, in 1 family combining DM1 and BrS. We screened the known BrS susceptibility genes. We characterized an SCN5A mutation using whole-cell patch-clamp experiments associated with cell surface biotinylation.

Results: The proband, a 15-year-old female, was a survivor of out-of-hospital cardiac arrest with ventricular fibrillation. She combined a DMPK CTG expansion from the father's side and an SCN5A mutation (S910L) from the mother's side. S910L is a trafficking defective mutant inducing a dominant negative effect when transfected with wild-type Nav1.5. This loss-of-function SCN5A mutation caused a Brugada phenotype during the mother's ajmaline test. Surprisingly, in the father, a DM1 patient without SCN5A mutation, ajmaline also unmasked a Brugada phenotype. Furthermore, association of both genetic abnormalities in the proband exacerbated the response to ajmaline with a massive conduction defect.

Conclusion: Our study is the first to describe the deleterious effect of DM1 on clinical expression of a loss-of-function SCN5A mutation and to show a provoked BrS phenotype in a DM1 patient. The modification of the ECG pattern by ajmaline supports the hypothesis of a link between DM1 and Nav1.5 loss of -function.
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http://dx.doi.org/10.1016/j.hrthm.2014.04.026DOI Listing
August 2014
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