Publications by authors named "Sylvie Levesque"

55 Publications

Portrayal of Domestic Violence Trajectories During the Perinatal Period.

Violence Against Women 2021 Jun 15:10778012211014564. Epub 2021 Jun 15.

CHU Sainte-Justine, Montréal, Québec, Canada.

Domestic violence during the perinatal period (DVPP) refers to the various ways that women's partners or ex-partners control and coerce them during pregnancy and the 2 years postpartum. From the descriptions of 17 women with firsthand experience of DVPP, this article reports on its manifestations and the associated contexts. The results reveal escalating violence, diverse forms of violence, and exacerbated consequences over the perinatal period. The contexts that pose additional challenges for the women include financial precariousness and the partner's substance abuse, and to a lesser extent the residential situation.
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http://dx.doi.org/10.1177/10778012211014564DOI Listing
June 2021

Colchicine for community-treated patients with COVID-19 (COLCORONA): a phase 3, randomised, double-blinded, adaptive, placebo-controlled, multicentre trial.

Lancet Respir Med 2021 May 27. Epub 2021 May 27.

Montréal Health Innovations Coordinating Center, Montreal, QC, Canada.

Background: Evidence suggests a role for excessive inflammation in COVID-19 complications. Colchicine is an oral anti-inflammatory medication beneficial in gout, pericarditis, and coronary disease. We aimed to investigate the effect of colchicine on the composite of COVID-19-related death or hospital admission.

Methods: The present study is a phase 3, randomised, double-blind, adaptive, placebo-controlled, multicentre trial. The study was done in Brazil, Canada, Greece, South Africa, Spain, and the USA, and was led by the Montreal Heart Institute. Patients with COVID-19 diagnosed by PCR testing or clinical criteria who were not being treated in hospital were eligible if they were at least 40 years old and had at least one high-risk characteristic. The randomisation list was computer-generated by an unmasked biostatistician, and masked randomisation was centralised and done electronically through an automated interactive web-response system. The allocation sequence was unstratified and used a 1:1 ratio with a blocking schema and block sizes of six. Patients were randomly assigned to receive orally administered colchicine (0·5 mg twice per day for 3 days and then once per day for 27 days thereafter) or matching placebo. The primary efficacy endpoint was the composite of death or hospital admission for COVID-19. Vital status at the end of the study was available for 97·9% of patients. The analyses were done according to the intention-to-treat principle. The COLCORONA trial is registered with ClinicalTrials.gov (NCT04322682) and is now closed to new participants.

Findings: Trial enrolment began in March 23, 2020, and was completed in Dec 22, 2020. A total of 4488 patients (53·9% women; median age 54·0 years, IQR 47·0-61·0) were enrolled and 2235 patients were randomly assigned to colchicine and 2253 to placebo. The primary endpoint occurred in 104 (4·7%) of 2235 patients in the colchicine group and 131 (5·8%) of 2253 patients in the placebo group (odds ratio [OR] 0·79, 95·1% CI 0·61-1·03; p=0·081). Among the 4159 patients with PCR-confirmed COVID-19, the primary endpoint occurred in 96 (4·6%) of 2075 patients in the colchicine group and 126 (6·0%) of 2084 patients in the placebo group (OR 0·75, 0·57-0·99; p=0·042). Serious adverse events were reported in 108 (4·9%) of 2195 patients in the colchicine group and 139 (6·3%) of 2217 patients in the placebo group (p=0·051); pneumonia occurred in 63 (2·9%) of 2195 patients in the colchicine group and 92 (4·1%) of 2217 patients in the placebo group (p=0·021). Diarrhoea was reported in 300 (13·7%) of 2195 patients in the colchicine group and 161 (7·3%) of 2217 patients in the placebo group (p<0·0001).

Interpretation: In community-treated patients including those without a mandatory diagnostic test, the effect of colchicine on COVID-19-related clinical events was not statistically significant. Among patients with PCR-confirmed COVID-19, colchicine led to a lower rate of the composite of death or hospital admission than placebo. Given the absence of orally administered therapies to prevent COVID-19 complications in community-treated patients and the benefit of colchicine in patients with PCR-proven COVID-19, this safe and inexpensive anti-inflammatory agent could be considered for use in those at risk of complications. Notwithstanding these considerations, replication in other studies of PCR-positive community-treated patients is recommended.

Funding: The Government of Quebec, the Bill & Melinda Gates Foundation, the National Heart, Lung, and Blood Institute of the US National Institutes of Health, the Montreal Heart Institute Foundation, the NYU Grossman School of Medicine, the Rudin Family Foundation, and philanthropist Sophie Desmarais.
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http://dx.doi.org/10.1016/S2213-2600(21)00222-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8159193PMC
May 2021

To Use or Not to Use the Term "Obstetric Violence": Commentary on the Article by Swartz and Lappeman.

Violence Against Women 2021 Jun 5;27(8):1009-1018. Epub 2021 Mar 5.

University of Ottawa, Ontario, Canada.

Based on the article by Swartz and Lappeman, we propose in this commentary to reflect on three central components linked to the concept of obstetric violence: the withdrawal of intentionality as a founding element of its recognition, the preponderant place given to the perspective of women and those affected by it, as well as the recognition of its sexist, gendered, and systemic character. We also discuss the epistemic injustice associated with obstetric violence. We stress the importance of including both health workers and health systems in the equation, even though they may be offended by the use of the term. We conclude by recalling that significant leadership must be exercised by health care workers and institutions to put an end to this form of violence.
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http://dx.doi.org/10.1177/1077801221996456DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8127656PMC
June 2021

Pulmonary Vein Stenosis After Atrial Fibrillation Ablation: Insights From the ADVICE Trial.

Can J Cardiol 2020 12 3;36(12):1965-1974. Epub 2020 Nov 3.

Montreal Health Innovations Coordinating Center (MHICC), Montreal, Quebec, Canada.

Background: Pulmonary vein (PV) stenosis is a complication of atrial fibrillation (AF) ablation. The incidence of PV stenosis after routine post-ablation imaging remains unclear and is limited to single-centre studies. Our objective was to determine the incidence and predictors of PV stenosis following circumferential radiofrequency ablation in the multicentre Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination (ADVICE) trial.

Methods: Patients with symptomatic AF underwent circumferential radiofrequency ablation in one of 13 trial centres. Computed tomographic (CTA) or magnetic resonance (MRA) angiography was performed before ablation and 90 days after ablation. Two blinded reviewers measured PV diameters and areas. PVs with stenosis were classified as severe (> 70%), moderate (50%-70%), or mild (< 50%). Predictors of PV stenosis were identified by means of multivariable logistic regression.

Results: A total of 197 patients (median age 59.5 years, 29.4% women) were included in this substudy. PV stenosis was identified in 41 patients (20.8%) and 47 (8.2%) of 573 ablated PVs. PV stenosis was classified as mild in 42 PVs (7.3%) and moderate in 5 PVs (0.9%). No PVs had severe stenosis. Both cross-sectional area and diameter yielded similar classifications for severity of PV stenosis. Diabetes was associated with a statistically significant increased risk of PV stenosis (OR 4.91, 95% CI 1.45-16.66).

Conclusions: In the first systematic multicentre evaluation of post-ablation PV stenosis, no patient acquired severe PV stenosis. Although the results are encouraging for the safety of AF ablation, 20.8% of patients had mild or moderate PV stenosis, in which the long-term effects are unknown.
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http://dx.doi.org/10.1016/j.cjca.2020.10.013DOI Listing
December 2020

Quality of Life and Health Care Utilization in the CIRCA-DOSE Study.

JACC Clin Electrophysiol 2020 08;6(8):935-944

Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada; Montreal Health Innovations Coordinating Centre, Montreal, Québec, Canada.

Objectives: This study evaluated the impact of contact force-guided radiofrequency ablation versus cryoballoon ablation on quality of life and health care utilization.

Background: Traditional outcome parameters, such as arrhythmia-free survival, are insufficient to evaluate the clinical impact of atrial fibrillation (AF), as it fails to the capture patient- and health system-level differences in treatment approaches.

Methods: The CIRCA-DOSE (Cryoballoon Vs. Contact-Force Atrial Fibrillation Ablation) study randomly assigned 346 patients with drug-refractory paroxysmal AF to contact force-guided radiofrequency or cryoballoon ablation. Health-related quality-of-life (HRQOL) was assessed at baseline, and at 6 and 12 months post-ablation using a disease-specific and generic HRQOL instruments. Health care utilization (hospitalization, emergency department visits, and cardioversion) and antiarrhythmic drug use for the 12 months preceding ablation was compared with the 12 months following ablation.

Results: Disease-specific and generic HRQOL was moderately to severely impaired at baseline and improved significantly at 6 and 12 months of follow-up (median improvement in AFEQT [Atrial Fibrillation Effect on QualiTy of Life] score 32.4 [interquartile range: 17.7 to 48.9]). When compared with the 12 months pre-ablation, the proportion and absolute number of cardioversions decreased significantly (41.1% vs. 10.1% of patients, 137 vs. 35 events; p < 0.0001). Similar significant reductions in emergency department visits (66.7% vs. 25.1% of patients, 224 vs. 87 events; p < 0.0001), and hospitalizations (25.5% vs. 14.5% of patients, 86 vs. 50 events; p < 0.001) were observed. There were no significant differences between randomized groups.

Conclusions: In this multicenter randomized trial, catheter ablation with advanced-generation technologies resulted in a significant improvement in HRQOL and a significant reduction in health care utilization in the year following AF ablation. (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation [CIRCA-DOSE]; NCT01913522).
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http://dx.doi.org/10.1016/j.jacep.2020.04.017DOI Listing
August 2020

Influence of the Relational Context on Reproductive Coercion and the Associated Consequences.

Violence Against Women 2021 May 29;27(6-7):828-850. Epub 2020 May 29.

Université du Québec à Montréal, Canada.

Reproductive coercion (RC) refers to behaviors that interfere with contraception use or pregnancy and that limit reproductive autonomy. This article presents the results of a qualitative exploratory study of 21 young women in Canada who experienced RC perpetrated by an intimate partner along with the associated consequences. Results reveal that nonconsensual condom removal occurred more often in uncommitted relationships without violence, whereas pressure to become pregnant and pregnancy coercion occurred more often in committed relationships where other forms of violence were also present. Participants reported numerous repercussions on their psychological, sexual, and reproductive health and on their emotional and relational well-being.
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http://dx.doi.org/10.1177/1077801220917454DOI Listing
May 2021

How Adolescents, Mothers, and Fathers Qualitatively Describe Their Experiences of Co-Occurrent Problems: Intimate Partner Violence, Mental Health, and Substance Use.

J Interpers Violence 2020 Feb 6:886260519900968. Epub 2020 Feb 6.

Université Laval, Québec City, Québec, Canada.

This qualitative study examines the perceptions of mothers, fathers, and adolescents on the relations they see between intimate partner violence, mental health and substances use parental problems that co-occur in their family, and the mothers' and fathers' associated parenting challenges. The sample was composed of 43 people (15 mothers, 16 fathers, and 12 adolescents) who were directly affected by the co-occurrence of intimate partner violence and mental health or substances use parental problems. The participants were recruited with the collaboration of public and community organizations in the Province of Québec (Canada). The data were collected through semi-structured interviews and combined with a table detailing the specific problems identified by the participants. A thematic content analysis method was employed to do the coding, and a summary of the results was returned to some participants who agreed to collaborate with the validation of the results. The analysis revealed numerous and diverse relations between the interviewees' co-occurring problems, but two principal patterns emerged. The first one was chiefly observed in the comments made by mothers and adolescents who saw the co-occurring problems as being the consequence of the intimate partner violence on the mother. The second pattern was largely observed in the fathers' comments, who explained that the substance use problems came before the intimate partner violence and acted as an aggravating factor. The co-occurrence of intimate partner violence with other parental problems strongly affected the mothers' and fathers' parenting, making it more difficult to meet the children's needs. Considering the complexity and diversity of the experiences and needs of the mothers, fathers, and children in co-occurring situations, future studies should evaluate the services provided to these families and the coordination between the different concerned organizations.
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http://dx.doi.org/10.1177/0886260519900968DOI Listing
February 2020

Preoperative Diaphragm Function Is Associated With Postoperative Pulmonary Complications After Cardiac Surgery.

Crit Care Med 2019 12;47(12):e966-e974

Department of Anesthesia, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.

Objectives: Postoperative pulmonary complications increase mortality, length, and cost of hospitalization. A better diaphragmatic strength may help face an increased work of breathing postoperatively. We, therefore, sought to determine if a low preoperative diaphragm thickening fraction (TFdi) determined by ultrasonography helped predict the occurrence of postoperative pulmonary complications after cardiac surgery independently of indicators of frailty, sarcopenia, and pulmonary function.

Design: Prospective observational cohort study.

Setting: Montreal Heart Institute, an academic cardiac surgery center in Canada.

Patients: Adults undergoing nonemergency cardiac surgery.

Interventions: We measured the preoperative thickness of the right and left hemidiaphragms at their zone of apposition at end-expiration (Tdi,ee) and peak-inspiration (Tdi,ei) with ultrasonography. Maximal thickening fraction of the diaphragm during inspiration (TFdi,max) was calculated using the following formula: TFdi,max = (Tdi,ei-Tdi,ee)/Tdi,ee. We also evaluated other potential risk factors including demographic parameters, comorbidities, Clinical Frailty Scale, grip strength, 5-meter walk test, and pulmonary function tests. We repeated TFdi,max measurements within 24 hours of extubation. The primary composite outcome of this study was the occurrence of postoperative pulmonary complications, defined as pneumonia, clinically significant atelectasis, or prolonged mechanical ventilation (> 24 hr).

Measurement And Main Results: Of the 115 patients included, 34 (29.6%) developed postoperative pulmonary complications, including two with pneumonia, four with prolonged mechanical ventilation, and 32 with clinically significant atelectasis. Those with postoperative pulmonary complications had prolonged ICU and hospital length of stays. They had a lower TFdi,max (37% [interquartile range, 31-45%] vs 44% [interquartile range, 33-58%]; p = 0.03). In multiple logistic regression, a TFdi,max less than 38.1% was associated with postoperative pulmonary complications (odds ratio, 4.9; 95% CI, 1.81-13.50; p = 0.002). All patients who developed pneumonia or prolonged mechanical ventilation had a TFdi,max less than 38.1%. Respiratory rate and diabetes were also independently associated with postoperative pulmonary complications, while pulmonary function tests and the assessed indicators of frailty and sarcopenia were not.

Conclusions: A low preoperative TFdi,max can help to identify patients at increased risk of postoperative pulmonary complications after cardiac surgery.
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http://dx.doi.org/10.1097/CCM.0000000000004027DOI Listing
December 2019

Young Women's Acknowledgment of Reproductive Coercion: A Qualitative Analysis.

J Interpers Violence 2021 Aug 11;36(15-16):NP8200-NP8223. Epub 2019 Apr 11.

Université du Québec à Montréal, Canada.

Reproductive coercion (RC) is a form of violence perpetuated against women. It occurs when male partners adopt behaviors meant to control a woman's birth control or pregnancy despite her wishes. This amounts to interference with a woman's autonomy in reproductive decisions. The three main forms of RC are birth control sabotage (including nonconsensual condom removal), pregnancy coercion, and controlling the outcome of a pregnancy. This qualitative exploratory study examines issues in the acknowledgment of RC. Participants were 21 young women in Québec (Canada), who had experienced this form of violence. Results of individual semi-directed interviews reveal that RC can be difficult to acknowledge. A thematic analysis demonstrates that awareness is modulated by the manifestations of RC and by the emotional bond with the perpetrator. Acknowledgment of RC behavior varies according to the form that is experienced: Nonconsensual condom removal is the most readily identified, whereas acknowledgment of pregnancy pressure and pregnancy coercion takes longer, requiring repeated incidents before it is identified as a form of violence. In addition, acknowledgment is facilitated when relationships are casual and uncommitted compared with romantic and committed. Moreover, reading about the issue, confiding in a friend or acquaintance, and finding a new partner who respects one's reproductive rights facilitate RC acknowledgment. In contrast, not self-identifying as a victim, assuming responsibility for the incident, having a limited understanding of sexual violence, and experiencing other forms of violence with an intimate partner contribute to impede RC acknowledgment. Results are discussed in terms of practical implications for young adults and health care professionals.
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http://dx.doi.org/10.1177/0886260519842169DOI Listing
August 2021

Acute Right Ventricular Failure in Cardiac Surgery During Cardiopulmonary Bypass Separation: A Retrospective Case Series of 12 Years' Experience With Intratracheal Milrinone Administration.

J Cardiothorac Vasc Anesth 2019 03 13;33(3):651-660. Epub 2018 Sep 13.

Research Centre, Montreal Heart Institute, Montreal, Quebec, Canada; Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada. Electronic address:

Objective: To report the authors' 12 years of experience with intratracheal milrinone administration and to assess the efficacy and limitations of intratracheal milrinone bolus administration for the treatment of unexpected acute right ventricular (RV) failure in patients undergoing cardiac surgery.

Design: Retrospective analysis.

Setting: Single-center university hospital.

Participants: One hundred seventy-six patients (4.6%) undergoing on-pump cardiac surgery.

Interventions: Endotracheal tube administration of milrinone (5-mg bolus) after unexpected acute RV failure during separation from cardiopulmonary bypass (CPB) weaning. RV failure was defined as the simultaneous presence of all of the following criteria: (1) hemodynamic instability or difficult separation from CPB with associated elevated central venous pressure or abnormal RV pressure waveform, (2) >20% reduction of RV fractional area change from baseline evaluated by transesophageal echocardiography, and (3) anatomical visualization of impaired or absent RV wall motion by direct intraoperative visual inspection.

Measurements And Main Results: Intratracheal milrinone administration was found to improve RV failure in 109 patients (61.9%) whereas RV failure persisted in 67 patients (38.1%). Using a multiple logistic regression model, severely decreased left ventricular ejection fraction (<35% v >50%) (adjusted odds ratio [OR] 3.72; 95% confidence interval [CI] 1.2-11.3; p = 0.012), longer CPB time (adjusted OR 1.014; CI 1.01-1.02; p = 0.001) and elevated postoperative fluid balance (adjusted OR 1.39; CI 1.1-1.8; p = 0.02) were found to be significant predictors of persistent RV failure.

Conclusion: Intratracheal instillation of milrinone was associated with clinical improvement of RV failure occurring during separation from CPB in almost two-thirds of patients. Factors limiting its therapeutic efficacy include severe left ventricular dysfunction, increased fluid balance, and long CPB time.
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http://dx.doi.org/10.1053/j.jvca.2018.09.016DOI Listing
March 2019

ADCY9 (Adenylate Cyclase Type 9) Inactivation Protects From Atherosclerosis Only in the Absence of CETP (Cholesteryl Ester Transfer Protein).

Circulation 2018 10;138(16):1677-1692

Montreal Heart Institute, Canada (Y.R., V.D., M-E.H., D.R., M.M., P.G., G.Miquel, K.U., R.S., V.L., G.B., A.N., P-M.W., M.L.S., N.M., L.L., N.D., M-A.G., S.S., G.Mayer, A.R., F.M., M.R.B., E.T., D.R., E.R., J-C.T.).

Background: Pharmacogenomic studies have shown that ADCY9 genotype determines the effects of the CETP (cholesteryl ester transfer protein) inhibitor dalcetrapib on cardiovascular events and atherosclerosis imaging. The underlying mechanisms responsible for the interactions between ADCY9 and CETP activity have not yet been determined.

Methods: Adcy9-inactivated ( Adcy9) and wild-type (WT) mice, that were or not transgenic for the CETP gene (CETPtg Adcy9 and CETPtg Adcy9), were submitted to an atherogenic protocol (injection of an AAV8 [adeno-associated virus serotype 8] expressing a PCSK9 [proprotein convertase subtilisin/kexin type 9] gain-of-function variant and 0.75% cholesterol diet for 16 weeks). Atherosclerosis, vasorelaxation, telemetry, and adipose tissue magnetic resonance imaging were evaluated.

Results: Adcy9 mice had a 65% reduction in aortic atherosclerosis compared to WT ( P<0.01). CD68 (cluster of differentiation 68)-positive macrophage accumulation and proliferation in plaques were reduced in Adcy9 mice compared to WT animals ( P<0.05 for both). Femoral artery endothelial-dependent vasorelaxation was improved in Adcy9 mice (versus WT, P<0.01). Selective pharmacological blockade showed that the nitric oxide, cyclooxygenase, and endothelial-dependent hyperpolarization pathways were all responsible for the improvement of vasodilatation in Adcy9 ( P<0.01 for all). Aortic endothelium from Adcy9 mice allowed significantly less adhesion of splenocytes compared to WT ( P<0.05). Adcy9 mice gained more weight than WT with the atherogenic diet; this was associated with an increase in whole body adipose tissue volume ( P<0.01 for both). Feed efficiency was increased in Adcy9 compared to WT mice ( P<0.01), which was accompanied by prolonged cardiac RR interval ( P<0.05) and improved nocturnal heart rate variability ( P=0.0572). Adcy9 inactivation-induced effects on atherosclerosis, endothelial function, weight gain, adipose tissue volume, and feed efficiency were lost in CETPtg Adcy9 mice ( P>0.05 versus CETPtg Adcy9).

Conclusions: Adcy9 inactivation protects against atherosclerosis, but only in the absence of CETP activity. This atheroprotection may be explained by decreased macrophage accumulation and proliferation in the arterial wall, and improved endothelial function and autonomic tone.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.117.031134DOI Listing
October 2018

Risk Factors for Radial-to-Femoral Artery Pressure Gradient in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass.

J Cardiothorac Vasc Anesth 2018 04 15;32(2):692-698. Epub 2017 Sep 15.

Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; Department of Surgery, Division of Cardiovascular Critical Care, Montreal Heart Institute, Montreal, Quebec, Canada. Electronic address:

Objective: To identify risk factors associated with radial-to-femoral pressure gradient during cardiac surgery with cardiopulmonary bypass (CPB).

Design: This is a retrospective, observational study.

Setting: Single specialized cardiothoracic hospital in Montreal, Canada.

Participants: Consecutive patients that underwent heart surgery with CPB between 2005 and 2015 (n = 435).

Interventions: None.

Measurements And Main Results: A radial-to-femoral pressure gradient occurred in 146 patients of the 435 patients (34%). Based on the 10,000 bootstrap samples, simple logistic regression models identified the 17 most commonly significant variables across the bootstrap runs. Using these variables, a backward multiple logistic model was performed on the original sample and identified the following independent variables: body surface area (m) (odds ratio [OR] 0.08, 95% confidence interval [CI] 0.030-0.232), clamping time (minutes) (OR 1.01, 95% CI 1.007-1.018), fluid balance (for 1 liter) (OR 0.81, 95% CI 0.669-0.976), and preoperative hypertension (OR 1.801, 95% CI 1.131-2.868).

Conclusion: A radial-to-femoral pressure gradient occurs in 34% of patients during cardiac surgery. Patients at risk seem to be of smaller stature, hypertensive, and undergo longer and more complex surgeries.
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http://dx.doi.org/10.1053/j.jvca.2017.09.020DOI Listing
April 2018

Thromboprophylaxis for atrial arrhythmias in congenital heart disease: A multicenter study.

Int J Cardiol 2016 Nov 13;223:729-735. Epub 2016 Aug 13.

Co-PI, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Background: There is a paucity of data to guide decisions regarding thromboprophylaxis for atrial arrhythmias in congenital heart disease.

Methods: A retrospective multicenter cohort study enrolled patients with documented sustained atrial arrhythmias and congenital heart disease from 12 North American centers to quantify thromboembolic and bleeding rates associated with antiplatelet and anticoagulation therapy, and explore associated factors. A blinded committee adjudicated all qualifying arrhythmias and outcomes.

Results: A total of 482 patients, 45.2% female, age 32.0±18.0years, were followed for 11.3±9.4years since the qualifying arrhythmia. Antiplatelet therapy was administered to 37.8%, anticoagulation to 54.4%, and neither to 7.9%. Congenital heart disease complexity was simple, moderate, and severe in 18.5%, 34.4%, and 47.1%, respectively. Freedom from thromboembolic events was 84.7±2.7% at 15years, with no difference between anticoagulation versus antiplatelet therapy (P=0.97). Congenital heart disease complexity was independently associated with thromboembolic events, with rates of 0.00%, 0.93%, and 1.95%/year in those with simple, moderate, and severe forms (P<0.001). CHADS and CHADS-VASc scores were not predictive of thromboembolic risk. Annualized bleeding rates with antiplatelet and anticoagulation therapy were 0.66% and 1.82% (P=0.039). In multivariable analyses, anticoagulation [hazard ratio (HR) 4.76, 95% CI (1.05-21.58), P=0.043] and HAS-BLED score [HR 3.15, 95% CI (1.02, 9.78), P=0.047] were independently associated with major bleeds.

Conclusion: Current management of atrial arrhythmias in congenital heart disease is associated with a modest rate of thromboembolic events, which is predicted by disease complexity but not CHADS/CHADS-VASc scores. HAS-BLED score is applicable to the congenital population in predicting major bleeds.
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http://dx.doi.org/10.1016/j.ijcard.2016.08.223DOI Listing
November 2016

Redefining the Blanking Period After Catheter Ablation for Paroxysmal Atrial Fibrillation: Insights From the ADVICE (Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination) Trial.

Circ Arrhythm Electrophysiol 2016 08;9(8)

For the author affiliations, please see the Appendix.

Background: Early recurrences (ERs) of atrial tachyarrhythmia are common after catheter ablation of atrial fibrillation. A 3-month blanking period is recommended by current guidelines. This study sought to investigate the significance of ER during the first 3 months post ablation in predicting late recurrences and determine whether it varies according to timing.

Methods And Results: A total of 401 patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation were followed for 12 months with transtelephonic monitoring in the ADVICE (Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination) trial. Patients with atrial tachyarrhythmia ≥30 s within the 3-month blanking period were stratified according to the timing of ER. A total of 179 patients (44.6%) experienced their last episode of ER during the first (n=53), second (n=44), or third (n=82) month of the 3-month blanking period. One-year freedom from symptomatic atrial tachyarrhythmia was 77.2% in patients without ER compared with 62.6%, 36.4%, and 7.8% in patients with ER 1, 2, and 3 months post ablation, respectively (P<0.0001). Receiver operating curve analyses revealed a strong correlation between the timing of ER and late recurrence (area under the curve 0.82, P<0.0001). Corresponding hazard ratios for ER during the first, second, and third months were 1.84, 4.45, and 9.64, respectively.

Conclusions: This study validates the use of a blanking period after catheter ablation for paroxysmal atrial fibrillation but calls into question the 90-day cut-off value. In particular, >90% of patients with ER during the third month post ablation experience late recurrence by 1 year. However, pending further study, repeat ablation before 90 days cannot be routinely advocated.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01058980.
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http://dx.doi.org/10.1161/CIRCEP.115.003909DOI Listing
August 2016

A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients.

Can J Anaesth 2016 Oct 28;63(10):1140-53. Epub 2016 Jul 28.

Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, QC, Canada.

Purpose: Inhaled milrinone (iMil) has been used for the treatment of pulmonary hypertension (PH) but its efficacy, safety, and prophylactic effects in facilitating separation from cardiopulmonary bypass (CPB) and preventing right ventricular (RV) dysfunction have not yet been evaluated in a clinical trial. The purpose of this study was to investigate if iMil administered before CPB would be superior to placebo in facilitating separation from CPB.

Methods: High-risk cardiac surgical patients with PH were randomized to receive iMil or placebo after the induction of anesthesia and before CPB. Hemodynamic parameters and RV function were evaluated by means of pulmonary artery catheterization and transesophageal echocardiography. The groups were compared for the primary outcome of the level of difficulty in weaning from CPB. Among the secondary outcomes examined were the reduction in the severity of PH, the incidence of RV failure, and mortality.

Results: Of the 124 patients randomized, the mean (standard deviation [SD]) EuroSCORE II was 8.0 (2.6), and the baseline mean (SD) systolic pulmonary artery pressure (SPAP) was 53 (9) mmHg. The use of iMil was associated with increases in cardiac output (P = 0.03) and a reduction in SPAP (P = 0.04) with no systemic hypotension. Nevertheless, there was no difference in the combined incidence of difficult or complex separation from CPB between the iMil and control groups (30% vs 28%, respectively; absolute difference, 2%; 95% confidence interval [CI], -14 to 18; P = 0.78). There was also no difference in RV failure between the iMil and control groups (15% vs 14%, respectively; difference, 1%; 95% CI, -13 to 12; P = 0.94). Mortality was increased in patients with RV failure vs those without (22% vs 2%, respectively; P < 0.001).

Conclusion: In high-risk cardiac surgery patients with PH, the prophylactic use of iMil was associated with favourable hemodynamic effects that did not translate into improvement of clinically relevant endpoints. This trial was registered at ClinicalTrials.gov; identifier: NCT00819377.
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http://dx.doi.org/10.1007/s12630-016-0709-8DOI Listing
October 2016

Adenosine-guided pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation: an international, multicentre, randomised superiority trial.

Lancet 2015 Aug 23;386(9994):672-9. Epub 2015 Jul 23.

Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada.

Background: Catheter ablation is increasingly used to manage atrial fibrillation, but arrhythmia recurrences are common. Adenosine might identify pulmonary veins at risk of reconnection by unmasking dormant conduction, and thereby guide additional ablation to improve arrhythmia-free survival. We assessed whether adenosine-guided pulmonary vein isolation could prevent arrhythmia recurrence in patients undergoing radiofrequency catheter ablation for paroxysmal atrial fibrillation.

Methods: We did this randomised trial at 18 hospitals in Australia, Europe, and North America. We enrolled patients aged older than 18 years who had had at least three symptomatic atrial fibrillation episodes in the past 6 months, and for whom treatment with an antiarrhythmic drug failed. After pulmonary vein isolation, intravenous adenosine was administered. If dormant conduction was present, patients were randomly assigned (1:1) to additional adenosine-guided ablation to abolish dormant conduction or to no further ablation. If no dormant conduction was revealed, randomly selected patients were included in a registry. Patients were masked to treatment allocation and outcomes were assessed by a masked adjudicating committee. Patients were followed up for 1 year. The primary outcome was time to symptomatic atrial tachyarrhythmia after a single procedure in the intention-to-treat population. The trial is registered with ClinicalTrials.gov, number NCT01058980.

Findings: Adenosine unmasked dormant pulmonary vein conduction in 284 (53%) of 534 patients. 102 (69·4%) of 147 patients with additional adenosine-guided ablation were free from symptomatic atrial tachyarrhythmia compared with 58 (42·3%) of 137 patients with no further ablation, corresponding to an absolute risk reduction of 27·1% (95% CI 15·9-38·2; p<0·0001) and a hazard ratio of 0·44 (95% CI 0·31-0·64; p<0·0001). Of 115 patients without dormant pulmonary vein conduction, 64 (55·7%) remained free from symptomatic atrial tachyarrhythmia (p=0·0191 vs dormant conduction with no further ablation). Occurrences of serious adverse events were similar in each group. One death (massive stroke) was deemed probably related to ablation in a patient included in the registry.

Interpretation: Adenosine testing to identify and target dormant pulmonary vein conduction during catheter ablation of atrial fibrillation is a safe and highly effective strategy to improve arrhythmia-free survival in patients with paroxysmal atrial fibrillation. This approach should be considered for incorporation into routine clinical practice.

Funding: Canadian Institutes of Health Research, St Jude Medical, Biosense-Webster, and M Lachapelle (Montreal Heart Institute Foundation).
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http://dx.doi.org/10.1016/S0140-6736(15)60026-5DOI Listing
August 2015

Intimate Partner Violence Among Pregnant Young Women: A Qualitative Inquiry.

J Interpers Violence 2016 Nov 11;31(19):3282-3301. Epub 2016 Jul 11.

2 Université de Montréal, Québec, Canada.

This article explores intimate partner violence (IPV) as experienced by young women during the perinatal period. Using purposive sampling, data pertaining to the experiences of 10 young mothers were gathered through on-site participative observation and individual in-depth interviews. Interviews were coded in an inductive way to reflect the experiences of the participants before pregnancy and following pregnancy confirmation. Overall, the analyses of different manifestations of IPV and their contexts reveal the difficulty these young mothers experience in identifying themselves as a victim of IPV and in categorizing their partner's acts as intimate violence. The fear of family separation and the desire to protect their child contributed to the complexity of violence experienced in a context of motherhood. This article also reflects on the limits of data collection on this subject through comparison of the results of the interviews with the results of the Revised Conflict Tactics Scale (CTS-2). Further research is needed to provide more insight into victimization among young mothers and to inform interventions with the goal of helping young women overcome the intersecting challenges of violence and motherhood.
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http://dx.doi.org/10.1177/0886260515584349DOI Listing
November 2016

Efficacy of amiodarone in patients with atrial fibrillation with and without left ventricular dysfunction: a pooled analysis of AFFIRM and AF-CHF trials.

J Cardiovasc Electrophysiol 2014 Dec 7;25(12):1306-13. Epub 2014 Oct 7.

Electrophysiology Service, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.

Introduction: Despite amiodarone's established safety profile in the setting of heart failure, it is unknown whether its impact on cardiovascular outcomes in patients with atrial fibrillation is modulated by left ventricular function.

Methods And Results: A pooled analysis of 3,307 patients (age 68.0 ± 0.2 years; 31.1% female) enrolled in AFFIRM and AF-CHF trials was conducted to assess the effect of rhythm control with amiodarone on cardiovascular outcomes, according to left ventricular systolic function. In amiodarone-treated patients (N = 1,107), freedom from recurrent atrial fibrillation was 84% and 45% at 1 and 5 years, respectively, with no differences according to left ventricular function (P = 0.8754). Similarly, the adjusted proportion of time spent in atrial fibrillation (15.0 ± 1.8%) did not vary according to ventricular function (P = 0.6094). Over 40.0 ± 0.3 months of follow-up, 1,963 (59.4%) patients required at least one hospitalization, 1,401 (42.6%) of whom had cardiovascular-related hospitalizations. Adjusted all-cause and cardiovascular hospitalization rates were similar with amiodarone versus rate control in all patients and in subgroups with and without severe left ventricular dysfunction. A total of 729 (22.0%) patients died, 498 (15.1%) from cardiovascular causes. Adjusted all-cause and cardiovascular mortality rates were similar with amiodarone versus rate control overall and in subgroups with and without severe left ventricular dysfunction.

Conclusion: Amiodarone's efficacy in maintaining sinus rhythm and reducing the burden of atrial fibrillation is similar in the presence or absence of severe left ventricular dysfunction. Rhythm control with amiodarone is associated with comparable hospitalization and mortality rates to rate control in patients with and without left ventricular dysfunction.
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http://dx.doi.org/10.1111/jce.12535DOI Listing
December 2014

Acute intraoperative effect of intravenous amiodarone on right ventricular function in patients undergoing valvular surgery.

Eur Heart J Acute Cardiovasc Care 2015 Aug 1;4(4):316-25. Epub 2014 Sep 1.

Department of Preventive and Social Medicine, Université de Montréal, Canada.

Background: Amiodarone is commonly used in the acute care setting. However the acute hemodynamic and echocardiographic effect of intravenous amiodarone administered intraoperatively on right ventricular (RV) systolic and diastolic function using transesophageal echocardiography (TEE) has not been described.

Methods: The study design was a randomized controlled trial in elective cardiac surgical patients undergoing valvular surgery. Patients received an intravenous loading dose of 300 mg of either amiodarone or placebo in the operating room, followed by an infusion of 15 mg/kg for two days. Hemodynamic profiles, echocardiographic measurement of RV and left ventricular (LV) dimensions, Doppler interrogation of tricuspid and mitral valve, hepatic and pulmonary venous flow combined with tissue Doppler imaging of the tricuspid and mitral valve annulus were obtained before and after bolus.

Results: Although more patients in the placebo group had chronic obstructive lung disease (14 vs 6, p=0.05) and diabetes (14 vs 5; p=0.0244), there was no difference in terms of baseline hemodynamic, 2D and Doppler variables. After bolus, a significant increase in pulmonary artery pressure, central venous pressure and pulmonary vascular resistance index (p<0.05) was observed in the amiodarone group with reduction in systolic to diastolic (S/D) ratio of the hepatic (p=0.0247) and pulmonary venous (p=0.0052) velocity.

Conclusion: Acute administration of amiodarone is associated with alteration in RV diastolic properties and has minimal negative inotropic effect on RV systolic function in cardiac surgical patients with valvular disease.
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http://dx.doi.org/10.1177/2048872614549102DOI Listing
August 2015

Cardiometabolic and traditional cardiovascular risk factors and their potential impact on macrovascular and microvascular function: preliminary data.

Clin Hemorheol Microcirc 2015 ;59(1):53-65

Cardiovascular Prevention and Rehabilitation Centre (Centre ÉPIC), Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.

We studied the relationship between cardiovascular status (CV) and risk factor numbers, macrovascular (flow mediated dilatation: FMD) and microvascular function using near-infrared spectroscopy (NIRS) in adults with different CV status. Seventy adults with different CV status (27 controls, 18 metabolic syndrome (MetS) and 25 coronary heart disease (CHD) patients) underwent a 5-min forearm arterial occlusion in supine position. High-resolution ultrasound examination of the brachial artery was performed during 1 minute at rest and 45 to 120 seconds after cuff release. Oxy, de-oxy and total hemoglobin signals (O2Hb, HHb and tHb) were measured continuously with NIRS on brachio-radialis muscle. FMD was reduced in CHD patients (P<0.05) compared to controls. Max. amplitude of O2Hb and Hmax of tHb were reduced (P<0.05) in MetS patients vs. controls. Post-deflation area under the curve (A.U.C) of O2Hb was lower in CHD (P<0.01) patients vs. controls and MetS patients. Independent predictors of microvascular function (A.U.C of O2Hb) were abdominal obesity and LDL-cholesterol whereas macrovascular function (FMD) was predicted by CV status. Only A.U.C of O2Hb related to CV risk numbers whereas FMD was not. Although macro and microvascular function were impaired in MetS and CHD patients, microvascular function was more strongly related to CV risk factors.
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http://dx.doi.org/10.3233/CH-141816DOI Listing
November 2015

Percutaneous paravalvular leak reduction: procedural and long-term clinical outcomes.

Can J Cardiol 2013 Nov;29(11):1422-8

From the Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada; From the Department of Medical Specialties, Cardiology Division, Université de Genève, Geneva, Switzerland.

Background: Significant paravalvular leak (PVL) after prosthetic replacement can result in hemolysis and/or congestive heart failure (CHF). Percutaneous PVL reduction (PPVR) represents an alternative to repeat surgery for a selected population. The purpose of this study was to assess the procedural and long-term clinical efficacy of percutaneous PPVR and its effect on survival free of rehospitalization for CHF, surgical reintervention, and death.

Methods: We analyzed a cohort of 56 consecutive patients who underwent 61 PPVRs in our institution between June 2001 and December 2010. Procedural success was defined as a reduction in regurgitation severity free from procedural complications. Patients were followed-up for vital status, clinical events, and symptoms.

Results: Patients were aged 65 ± 11 years, with an average logistic EuroSCORE of 19 ± 14%. Indications for PPVR included CHF (61%), hemolysis (9%), or both (30%), caused by mitral (n = 44) or aortic (n = 12) PVL. Procedural success was achieved in 75% of cases. Three major complications, including 2 deaths, occurred during the initial 30-day follow-up in the 42 patients who were treated with a device. After adjusting for the logistic EuroSCORE, prosthesis type (mitral vs aortic), and time interval since the last valve surgery, a successful PPVR was associated with a better survival free of rehospitalisation for CHF, need for surgical reintervention, and death compared with patients with a failed PPVR. (hazard ratio = 0.34; 95% confidence interval, 0.17-0.71).

Conclusions: PPVR is associated with a reasonable rate of procedural success and favourable cardiovascular outcomes, and represents an appropriate option when technically possible.
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http://dx.doi.org/10.1016/j.cjca.2013.07.800DOI Listing
November 2013

Hemodynamic pressure waveform analysis in predicting fluid responsiveness.

J Cardiothorac Vasc Anesth 2013 Aug;27(4):676-80

Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada.

Objective: To assess the usefulness of central venous pressure (CVP), diastolic right ventricular pressure, and pulmonary capillary wedge pressure (PCWP) waveform analysis in predicting fluid responsiveness.

Design: A prospective observational study.

Setting: Tertiary care university hospital.

Patients: Forty-four patients undergoing coronary artery bypass grafting.

Interventions: Analysis of the a/v wave ratio of the PCWP, CVP, and right ventricular dP/dt to predict an increase in stroke volume >15% after the administration of 500 mL of colloid.

Measurements And Main Results: Forty-four patients were enrolled in this study and 7 were excluded. There were 24 responders and 13 nonresponders. No differences in mean CVP and PCWP values between the responders and the nonresponders were found. The only parameter associated with a significant response to volume infusion was the ratio of the a/v waves of the PCWP tracing (p = 0.0001). The performance of the a/v wave ratio>1 of the PCWP tracing in predicting fluid responsiveness was evaluated by constructing a receiver operating characteristic curve. The area under the receiver operating characteristic curve was 0.89 (95% confidence interval, 0.79-0.99; p<0.05).

Conclusions: The a/v ratio measured on the PCWP tracing is a predictor of fluid responsiveness in patients with preserved left ventricular function undergoing coronary artery bypass grafting.
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http://dx.doi.org/10.1053/j.jvca.2012.11.002DOI Listing
August 2013

Atrial fibrillation and congestive heart failure: a cost analysis of rhythm-control vs. rate-control strategies.

Can J Cardiol 2013 Oct 7;29(10):1256-62. Epub 2013 Jun 7.

Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada.

Background: Atrial fibrillation (AF) is common in patients with heart failure. Rhythm- and rate-control strategies are associated with similar efficacy outcomes. We compared the economic impact of the 2 treatment strategies in patients with AF and heart failure from the province of Québec, Canada.

Methods: In a substudy of the Atrial Fibrillation and Congestive Heart Failure trial, health care expenditures of patients from Québec randomized to rhythm and rate-control treatment strategies were compared from a single-payer perspective using a cost-minimization approach. In-trial resource utilization and unit costs were estimated from Québec Health Insurance Board databases supplemented by disease-specific costs from the Ontario Case Costing Initiative.

Results: In all, 304 patients were included, aged 68 ± 9 years; 86% male; ejection fraction, 26% ± 6%. Baseline characteristics were similar in rhythm-control (n = 149) and rate-control (n = 155) groups. Arrhythmia-related costs accounted for 45% of total expenditures. Rate-control patients had fewer cardiac procedures (146 vs. 238, P < 0.001), driven by fewer cardioversions, and lower costs related to antiarrhythmic drugs (CAD $48 per patient [95% confidence interval {CI}, $21-$96] vs. $1319 per patient [95% CI, $1124-$1522]). However, these differences were offset by higher expenditures due to hospitalizations for noncardiovascular diagnoses, implantable cardiac arrhythmia devices, and noncardiovascular drugs in the rate-control group. The total cost per patient was not significantly different between rhythm-control ($72,764 [95% CI, $61,575-$85,145]) and rate-control ($78,767 [95% CI, $67,101-$92,139]) strategies.

Conclusion: In the study population, the therapeutic strategy used to manage AF in patients with severe heart failure appears to have little influence on the overall financial burden, which remains substantial.
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http://dx.doi.org/10.1016/j.cjca.2013.03.005DOI Listing
October 2013

Mineralocorticoid receptor antagonists and cardiovascular mortality in patients with atrial fibrillation and left ventricular dysfunction: insights from the Atrial Fibrillation and Congestive Heart Failure Trial.

Circ Heart Fail 2012 Sep 12;5(5):586-93. Epub 2012 Jul 12.

Montreal Heart Institute, Montreal Heart Institute Coordinating Center, and Université de Montréal, Montreal, QC, Canada.

Background: Patients with heart failure (HF) and atrial fibrillation (AF) may differ from the larger HF population with respect to comorbidities, including renal impairment and overall prognosis. Associated cardiorenal interactions may mitigate the effects of pharmacological agents. Our primary objective was to assess the impact of mineralocorticoid receptor antagonists on cardiovascular mortality in patients with AF and HF enrolled in the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial.

Methods And Results: All 1376 patients randomized in the AF-CHF trial were included. The median baseline creatinine was 105.2 (Q1 88.4, Q3 125.0) μmol/L, and the median estimated glomerular filtration rate was 62.3 (Q1 49.0, Q3 77.2) mL/min per 1.73 m(2). The renal function was moderately or severely impaired (ie, estimated glomerular filtration rate <60 mL/min per 1.73 m(2)) in 46.5% of patients. In multivariable analyses, increased creatinine was associated with worsening HF but not mortality. Mineralocorticoid receptor antagonists were prescribed in 44.8% and were independently associated with a 1.4-fold increase in total mortality (hazard ratio, 1.4; 95% CI [1.1-1.8]; P=0.005) and a 1.4-fold increase in cardiovascular mortality (hazard ratio, 1.4; 95% CI [1.1-1.9]; P=0.009). This was driven by an increased incidence of sudden cardiac death (hazard ratio, 2.0; 95% CI [1.3, 3.0]; P=0.001).

Conclusions: Renal dysfunction was highly prevalent in patients with AF and HF. Mineralocorticoid receptor antagonists were independently associated with an increased incidence of cardiovascular deaths, predominantly of presumed arrhythmic cause. Although these provocative findings merit prospective validation, they underscore the importance of careful monitoring of renal function and electrolytes in patients with AF and HF receiving mineralocorticoid receptor antagonists.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.111.965160DOI Listing
September 2012

Cardiac remodeling with rhythm versus rate control strategies for atrial fibrillation in patients with heart failure: insights from the AF-CHF echocardiographic sub-study.

Int J Cardiol 2013 May 13;165(3):430-6. Epub 2011 Sep 13.

Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.

Background: In patients with heart failure and atrial fibrillation, the AF-CHF (Atrial Fibrillation and Congestive Heart Failure) trial did not demonstrate the superiority of rhythm control (RhyC) over a rate control (RaC) strategy on cardiovascular mortality. Nevertheless, deleterious hemodynamic effects of atrial fibrillation can lead to further decrease in left ventricular (LV) function and progression of symptoms. This echocardiographic sub-study was designed to compare the effects of the two treatment strategies on LV ejection fraction (LVEF), chamber volumes and dimensions, valvular regurgitation and functional status.

Methods And Results: A total of 59 patients (29 RhyC, 30 RaC) aged 67±8 years (14% women), enrolled in the AF-CHF trial at the Montreal Heart Institute underwent standardized echocardiograms at baseline and at 12 months. Mean LVEF at baseline was severely depressed (RhyC: 27.0±4.9% and RaC: 27.6±7.4%, p=0.73), and improved to a similar degree in both groups (RhyC: +8.0±10.4% and RaC: +4.5±10.6, both p<0.05; p=0.19 for RhyC versus RaC). Other echocardiographic parameters, such as LV end-systolic volume index and degree of mitral and tricuspid regurgitation, remained unchanged. New York Heart Association functional class and distance walked in 6 min improved significantly in both groups (RhyC: +48.9±78.7 m and RaC: +47.2±96.7 m, both p≤0.01), with no difference between RhyC and RaC strategies.

Conclusions: Improvements in LVEF and functional status are observed after 12 months in patients with heart failure and atrial fibrillation, regardless of whether rate or rhythm control strategies are used.
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http://dx.doi.org/10.1016/j.ijcard.2011.08.077DOI Listing
May 2013

Oral ferrous sulfate does not increase preoperative hemoglobin in patients scheduled for hip or knee arthroplasty.

Ann Pharmacother 2011 Jun 10;45(6):764-70. Epub 2011 Jun 10.

University of Montreal, Montreal Heart Institute, Montreal, Quebec, Canada.

Background: Low hemoglobin (Hb) concentrations before lower limb joint replacement are associated with the need for blood transfusions and increased mortality. To optimize preoperative Hb, blood conservation protocols often recommend oral iron supplements, even in nonanemic patients.

Objective: To investigate the impact of ferrous sulfate on the change in Hb prior to hip or knee arthroplasty and evaluate the effect of oral iron on hematocrit, mean corpuscular volume (MCV), ferritin, and transferrin saturation, as well as its tolerability and treatment adherence.

Methods: We conducted a prospective, observational cohort study of adults with Hb concentrations between 10 and 15 g/dL who received iron supplementation prior to hip or knee arthroplasty. Systemic inflammatory diseases, vitamin B(12) or folate deficiency, and current use of iron supplements, intravenous iron, or erythropoietin were exclusion criteria. All participants were prescribed ferrous sulfate 300 mg 3 times daily for a minimum of 3 weeks. Complete blood cell counts and iron studies were performed before therapy and surgery.

Results: Eighty-seven patients with a mean (SD) Hb of 13.47 (0.84) g/dL were included in the study. Preoperative Hb decreased after treatment with iron (-0.14 [0.53] g/dL, p = 0.015). Hematocrit also declined (-0.6% [1.8%], p = 0.002), whereas ferritin increased (25.8 [38.6] ng/mL, p < 0.001). No significant change was seen in MCV and transferrin saturation. The most common adverse effects were constipation (33.3%), heartburn (13.8%), and abdominal pain (12.6%). The adherence rate was 67.1%.

Conclusions: Oral ferrous sulfate supplementation is not an effective method to increase preoperative Hb in patients scheduled for hip or knee arthroplasty, and its use is associated with adverse effects.
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http://dx.doi.org/10.1345/aph.1P757DOI Listing
June 2011

[Giving birth at 16, without violence: a possible reality? Empirical data and critical reflection].

Authors:
Sylvie Lévesque

Sante Ment Que 2010 ;35(1):195-219

l'Université de Montréal Maîtrise en sexologie de l'UQAM Institut national de santé publique du Québec.

Violence between adolescents during teen pregnancy is relatively new in terms of scientific interest and clinical preoccupations. It is an alarming situation, given that 1) its prevalence ranges from 5 % to 29 % according to the literature; 2) consequences for both the mother's and baby's health are numerous at physical, psychological and sexual levels; 3) scientific and empirical knowledge regarding the phenomenon is limited and diminishes efficacy and relevance of current interventions. It therefore appears of major importance to acquire better knowledge of various ecological factors in order to implement preventative care and services that will allow them as well as their children to thrive in adverse conditions and have access to a safe and supportive environment.
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http://dx.doi.org/10.7202/044804arDOI Listing
January 2011

Effect on bleeding, time to revascularization, and one-year clinical outcomes of the radial approach during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction.

Am J Cardiol 2010 Jul;106(2):148-54

Division of Interventional Cardiology, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.

The radial approach during percutaneous coronary intervention (PCI) has been reported to reduce the incidence of bleeding complications. However, the radial approach still accounts for <10% of procedures worldwide and only 1% in the United States. Our objective was to compare the effect of radial versus femoral vascular access on the time to reperfusion, incidence of bleeding complications, and overall clinical outcomes in the setting of primary PCI. We prospectively collected data on all patients undergoing primary PCI at the Montreal Heart Institute from April 1, 2007 to March 30, 2008. The time to revascularization and major bleeding were prespecified as a co-primary end point, and major adverse cardiac events, including death, myocardial infarction, and target vessel revascularization within 12 months, were considered a secondary end point. A total of 489 patients were included in the present longitudinal cohort study, 234 in the femoral group and 254 in the radial group. In the propensity-adjusted model, the use of the femoral approach was a strong independent predictor of bleeding (odds ratio 4.22, 95% confidence interval 3.17 to 10.60). No significant difference between the radial and femoral groups was observed relative to the time to revascularization (21.4 +/- 11.8 minutes vs 22.8 +/- 10.3 minutes, respectively; p = 0.68). Moreover, the radial approach was associated with a decreased risk of major adverse cardiac events (odds ratio 0.31, 95% confidence interval 0.10 to 0.94). In conclusion, primary PCI using the radial approach was associated with a fourfold reduction in major bleeding, without compromising the time to revascularization. Moreover, the radial approach was associated with a significant reduction in major adverse cardiac events at 12 months.
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http://dx.doi.org/10.1016/j.amjcard.2010.02.028DOI Listing
July 2010

Remodeling is a more important determinant of lumen size than atheroma burden in left main coronary artery disease.

Am Heart J 2010 Jul;160(1):188-194.e1

Department of Medicine, Montreal Heart Institute/Université de Montréal, Montreal, Quebec, Canada.

Background: Left main coronary artery (LMCA) disease influences survival; however, the predictors of LMCA changes over time are incompletely understood.

Methods: Paired intravascular ultrasound (IVUS) and core laboratory analyses were performed in a standardized fashion in 207 subjects (mean +/- SD age 58 +/- 10 years, 80% men). The average follow-up duration was 18 months (range 12-24 months). The IVUS measurements were first obtained at the smallest lumen area and the largest plaque area at follow-up and the corresponding positions in the LMCA were then measured at baseline.

Results: The LMCA percentage of atheroma area at baseline was 38.2% +/- 11.8%, and 133 patients (64%) experienced an increase in percentage of atheroma area. Change in lumen area correlated positively with change in total vessel area (R = 0.85, P < .0001) and negatively with change in percentage of atheroma area (R = -0.58, P < .0001). Change in plaque area correlated well with change in total vessel area (R = 0.64, P < .0001) but only weakly with change in lumen area (r = 0.14, P = .039). Although LMCA length correlated negatively with baseline lumen area and total vessel area, it did not correlate with their changes over time. On multivariable analyses, current smoking predicted an increase in percentage of atheroma area (P = .0013) and plaque area (P = .0041). Height negatively predicted change in percentage of atheroma area (P = .001).

Conclusions: The LMCA lumen dimensions are more tightly linked with remodeling than with atheroma progression/regression.
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http://dx.doi.org/10.1016/j.ahj.2010.03.037DOI Listing
July 2010
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