[Electrical storm in patients with Automatic Implantable Defibrillator : A single Center study]

BACKGROUND

Electrical storms (ES) are serious cardiac emergencies associated with increased short-term mortality. The true incidence of ES in patients with an implantable cardioverter defibrillator (ICD) is still difficult to estimate because of the heterogeneous definition. The clinical presentation is variable and its management is multidisciplinary.

OBJECTIVE

The aim of the study was to analyze the epidemiological profile and evolution of a group of patients implanted with an ICD who had electrical storms detected by a home monitoring system.

METHODS

This is a single-center retrospective observational study, which included 14 patients who were implanted with ICDs, for primary or secondary prevention between 2008 and 2021. All of them were followed by home monitoring. All these patients had an ES detected by home monitoring and authenticated by ECG.

RESULTS

The mean age of the patients at the time of onset of the electrical storm was 75.4 ± 14.5 years, with extremes ranging from 49 to 101 years. Most of patients (n = 11) were male. The majority of them had underlying ischaemic cardiomyopathy (n = 12). In a third of cases (n = 5) patients were implanted for secondary prevention. The electrical storm was related to recurrent episodes of VT. No cases of VF were detected. Syncope was the most frequent clinical presentation (four patients). Nine patients received internal shocks, with an average of four shocks per patient. The triggering factor was myocardial ischaemia in four cases. Majority of patients were managed in the cardiac intensive care unit. Two patients were admitted to the intensive care unit. In addition to anti-arrhythmic treatment with amiodarone and beta blockers. Nine patients underwent ablation of ventricular tachycardia focus. Mortality was high (in half of the cases) mainly due to a cardiogenic shock.

CONCLUSION

This study shows that OR remain rare, but are still associated with high mortality. Home monitoring makes it possible to manage them earlier.

[Rythmology activity in France and consequences of new thresholds approvals]

BACKGROUND

Interventional rhythmology activity (electrophysiology and pacing) has progressed in France during the last decade. The objective of this article is to assess the distribution of this activity depending on the type of centre (public, university or non-university, private). As the French government issued a new regulation regarding rhythmology activity in 2022, the impact of this regulation on activity distribution has been evaluated.

METHODOLOGY

All French data activity can be evaluated after accessing to a national database called PMSI [Programme de Médicalisation des Systèmes d'Information]. Based on data collected in year 2021, the level of activity of the different centres, and the impact of the new criteria of the French regulation regarding rhythmology activity have been analysed.

RESULTS

About 200,000 arrhythmias interventions have been done in France in 2021 in 382 centres. According to the new criteria of the French regulation, 66% responded to level A (diagnostic electrophysiology, single- and dual-chamber pacing), 68% for level B (A+ right atrial ablation, implantable automatic defibrillator, cardiac resynchronisation therapy) and 70% for level C (B + left atrial and ventricular ablation). 1/4 of the centres do not meet criteria for level A activity, and 1/5 of them for levels B and C CONCLUSIONS: This work showed that immediat and systematic application of new threshold could be threatening for 1/4 of A center and 1/5 of B or C center. The priority will be to reinforce existing centres before allowing new centres to perform arrhythmias management activity in France.

Perceptions and satisfaction of patients with chronic heart failure when using a remote monitoring web application named Satelia® Cardio

INTRODUCTION

The use of telehealth, such as remote patient monitoring (RPM), for chronic heart failure (CHF) impacts patient pathways. Patient-centricity in chronic disease management is valuable. Even though RPM is recommended in practice, the evaluation of patient satisfaction has been limited to date. The objective of this study was to assess the perceptions and satisfaction of patients with CHF when using RPM.

METHODS

A voluntary declarative survey was conducted with users of Satelia® Cardio, an RPM web application which was included in an experimental model program in France funded by the ETAPES program initiative sponsored by the French Ministry of Health. Monitoring was based on patient-reported outcomes (seven questions on symptoms, one question on weight) which were answered online (digitally literate patients) or by phone with a nurse (patients with poor digital literacy). The survey included questions on perceived usefulness, ease of use and impact on quality of life (QoL).

RESULTS

Overall, 87% of the 825 patients were satisfied with having their CHF digitally monitored. Patients found that the application was easy to use (94%), problem free (95%), provided well-timed notifications (98%), easily accessible (96.5%), understandable (89%), and did not require an unreasonable amount of time to answer questions (99%). Most patients felt that RPM helped physicians provide better care during their follow-ups (70%, mean score: 7.98/10) and 45% of the digitally literate patients indicated an improved QoL.

CONCLUSION

Poor digitally literate patients may need human-based or assisted RPM. Patients monitored daily for CHF through RPM expressed strong satisfaction and acceptance.

Impact of peri-procedural management of direct oral anticoagulants on pocket haematoma after cardiac electronic device implantation: the StimAOD multicentre prospective study

AIMS

The study aims to investigate the impact of direct oral anticoagulant (DOAC) management on the incidence of pocket haematoma in patients undergoing pacemaker or implantable cardioverter-defibrillator implantation.

METHODS AND RESULTS

All consecutive patients receiving DOAC and undergoing cardiac electronic device implantation were included in a large multicentre prospective observational study (NCT03879473). The primary endpoint was clinically relevant haematoma within 30 days after implantation. Overall, 789 patients were enrolled [median age 80 (IQR 72-85) years old, 36.4% women, median CHA2DS2-VASc score 4 (IQR 0-8)], of which 632 (80.1%) received a pacemaker implantation. Antiplatelet therapy was combined with DOAC in 146 patients (18.5%). Direct oral anticoagulants (DOACs) were interrupted 52 (IQR 37-62) h before the procedure and resumed 31 (IQR 21-47) h later. Ninety-six percent of the patients had at least 12 h DOAC interruption before the procedure, and 78% had at least 12 h DOAC interruption after the procedure. Overall, anticoagulation was interrupted for 72 (IQR 48-96) h. Pre- or post-procedural heparin bridging was used in 8.2% and 3.9%, respectively. Timing of DOAC interruption of resumption was not associated with clinically relevant haematoma. Clinically relevant haematoma occurred in 26 patients (3.3%), and thromboembolic events occurred in 5 patients (0.6%).

CONCLUSION

In this large real-life registry where most patients had DOAC interruption, clinically relevant haematoma was rare. Despite DOAC interruption and high CHA2DS2-VASc score, thromboembolic events occurred seldomly, highlighting that bleeding exceeds thromboembolic risk in this peri-procedural period. Future research is needed to identify risk factors for clinically relevant haematoma and meaningfully guide clinicians in optimizing DOAC management.

[Where are done electrophysiology procedures in France and what is the expected evolution ?]

INTRODUCTION

Interventional rhythmology activity (electrophysiology and pacing) has progressed in France during the last decade. The objective of this article was to assess the distribution of this activity depending on the type of centre (public, university or non-university, private). As the French government issued a new regulation regarding rhythmology activity in 2022, the impact of this regulation on activity distribution has been evaluated.

METHODOLOGY

All French data activity can be evaluated after accessing to a national database called PMSI [Programme de médicalisation des systèmes d'information]. Based on data collected in year 2019, the level of activity of the different centres, and the impact of the new criteria of the French regulation regarding rhythmology activity have been analysed.

RESULTS

About 180,000 arrhythmias interventions have been done in France in 2019 in 377 centres. According to the new criteria of the French regulation, only 76% responded to level A (diagnostic electrophysiology, single- and dual-chamber pacing), 52% for level B (A+ right atrial ablation, implantable automatic defibrillator, cardiac resynchronisation therapy) and 54% for level C (B + left atrial and ventricular ablation).

CONCLUSIONS

This work showed that approximately a quarter of the centres do not meet criteria for level A activity, and approximately half of them for levels B and C. The priority will be to reinforce existing centres before allowing new centres to perform arrhythmias management activity in France.

Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

Remote patient monitoring for chronic heart failure in France: When an innovative funding program (ETAPES) meets an innovative solution (Satelia® Cardio)

Introduction

Remote patient monitoring (RPM) is a telehealth activity to collect and analyze patient health or medical data. Its use has expanded in the past decade and has improved medical outcomes and care management of non-communicable chronic diseases. However, implementation of RPM into routine clinical activities has been limited. The objective of this study was to describe the French funding program for RPM (known as ETAPES) and one of the RPM solution providers (Satelia®) dedicated to chronic heart failure (CHF).

Methods

A descriptive assessment of both the ETAPES funding program and Satelia® RPM solution was conducted. Data were collected from official legal documents and information that was publicly available online from the French Ministry of Health.

Results and Discussion

ETAPES was formally created in 2016 based on previous legislation pertaining to the national health insurance funding strategy. However, it only started to operate in 2018. Patients with CHF were only eligible if they were at medium or high risk of re-hospitalization with a New York Heart Association (NYHA) score superior or equal to two and a BNP>100 pg/ml or NT pro BNP>1000 pg/ml. Medical monitoring was supported through the therapeutic education of a patient on the RPM model of care with a minimum of three training sessions during the first six months. The use of Satelia® Cardio is noteworthy since it relies only on symptomatic monitoring through which the patient manually reports their information by answering a simple questionnaire on a regular basis and does not rely on any connected devices.

Conclusion

Innovative funding programs and solutions for RPM need real-world evaluation in the future.

[Hypnosis rhythmology practice : Results of a French survey]

This survey evaluated hypnosis practice in French centres in June 2020. The survey was sent via email to different rhythmology centres in France and responses from cardiologists and nurses were obtained. We present here the preliminary results of this survey. Hypnosis was used on a regular basis in 7.5% of the centres and 13% of the participants received education on hypnosis. 75% of the participants were interested to have an education of hypnosis. The survey points the different possibilities of improvement of management of patients while having the different procedures.

The Importance of Appropriate Dosing of Nonvitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Patients with Atrial Fibrillation

Preventing thromboembolic events, while minimizing bleeding risks, remains challenging when managing patients with atrial fibrillation (AF). Several factors contribute to current dosing patterns of nonvitamin K antagonist oral anticoagulants (NOACs), including patient characteristics, comorbidities, and physician judgment. Application of NOAC doses inconsistent with the drug labels may cause patients to receive either subtherapeutic (increasing stroke risk) or supratherapeutic (increasing bleeding risk) anticoagulant levels. In clinical practice, under- or over-dosing of NOACs in patients with AF is not uncommon. This analysis of prospective and retrospective registry and database studies on NOAC use in patients with AF (with at least 250 patients in each treatment arm) showed that under-dosing may be associated with reduced effectiveness for stroke prevention, with similar or even increased bleeding than with the standard dose. This may reflect underlying conditions and patient factors that increase bleeding despite NOAC dose reduction. Such factors could drive the observed overuse of reduced NOAC dosages, often making the prescription of reduced-dose NOAC an intentional label deviation. In contrast, over-dosing more likely occurs accidentally; instead of providing benefits, it may be associated with worse safety outcomes than the standard dose, including increased bleeding risk and higher all-cause mortality rates. This review summarizes the main findings on NOAC doses usually prescribed to patients with AF in clinical practice.

Lack of efficacy of hydroxychloroquine and azithromycin in patients hospitalized for COVID-19 pneumonia: A retrospective study

Background

Hydroxychloroquine combined with azithromycin (HCQ/AZI) has initially been used against coronavirus disease-2019 (COVID-19). In this retrospective study, we assessed the clinical effects of HCQ/AZI, with a 28-days follow-up.

Methods

In a registry-study which included patients hospitalized for COVID-19 between March 15 and April 2, 2020, we compared patients who received HCQ/AZI to those who did not, regarding a composite outcome of mortality and mechanical ventilation with a 28-days follow-up. QT was monitored for patients treated with HCQ/AZI. Were excluded patients in intensive care units, palliative care and ventilated within 24 hours of admission. Three analyses were performed to adjust for selection bias: propensity score matching, multivariable survival, and inverse probability score weighting (IPSW) analyses.

Results

Overall, 203 patients were included: 60 patients treated by HCQ/AZI and 143 control patients. During the 28-days follow-up, 32 (16.3%) patients presented the primary outcome and 23 (12.3%) patients died. Propensity-score matching identified 52 unique pairs of patients with similar characteristics. In the matched cohort (n = 104), HCQ/AZI was not associated with the primary composite outcome (log-rank p-value = 0.16). In the overall cohort (n = 203), survival and IPSW analyses also found no benefit from HCQ/AZI. In the HCQ/AZI group, 11 (18.3%) patients prolonged QT interval duration, requiring treatment cessation.

Conclusions

HCQ/AZI combination therapy was not associated with lower in-hospital mortality and mechanical ventilation rate, with a 28-days follow-up. In the HCQ/AZI group, 18.3% of patients presented a prolonged QT interval requiring treatment cessation, however, control group was not monitored for this adverse event, making comparison impossible.

First experience with a ready-to-use solution for remote monitoring of patients suffering from heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Heart failure (HF) is associated with a high mortality rate and recurrent hospitalizations.

Purpose

To present the first data of the patients using Satelia® Cardio solution

Method

Satelia® Cardio is a HF patient management solution with a remote monitoring system and a therapeutic guidance by a dedicated-nurse phone platform, supported by the ETAPES Program. The system is accessible from any device and requiring no installation. After the inclusion, the patient is contacted by the nurse, he then receives an SMS alerts following cardiologist prescription (on regular basis), with a link leading to a web page on which he will answer 7 questions and enter his current body weight. Satelia® Cardio algorithm is based on these data inputs, their variability, and the weight. In case of worsening of symptoms, the cardiologist will be notified. Since Covid-19 lockdown, more than 1400 patients have been monitored with the solution.

Results

165 centers (306 cardiologists) are using Satelia® Cardio with 3540 HF patients monitored in the last 29 months. The patients with a mean age of 72 years (19-100) are predominantly males (67%), and mostly NYHA II/III (69%/31%) with a mean LVEF of 40%. The adherence to the system is very good (91%) with 78% of patients still monitored (n = 2787). The main reasons for stopping are related to the occurrence of death (205/753) or patient/HCP decision (392/753), or other reasons (156/753). Over the period of analysis, the HF patients answered to 163 700 questionnaires, generating 8210 alerts transmitted to the referent cardiologists.

Conclusion

Patient management solution with a remote monitoring system is key to improving the follow-up of HF patients. The solution Satelia® Cardio is an easy way to use a web application to monitor HF patients, especially on the current period of Covid-19 with a low rate of premature discontinuation. A further step will be to initiate studies to assess the potential benefits for both patients and HCPs  of such remote monitoring solution in HF.

[Organization and management of acute complete atrioventricular block: Results from a Multicenter National Survey]

BACKGROUND

Complete atrioventricular block (AVB3) may be an urgent potentially lifethreatening situation. Our objective was to describe the routine management of AVB 3, with emphasis on the organizational aspects.

METHODS

From September 2019 to November 2019, a prospective national survey including 28 questions was electronically sent to 100 physicians (Google Form).

RESULTS

The answers were collected from 93 physicians (response rate 93%). Permanent pacemaker implantation during weekends and nights (after 8PM) is possible for 49% of the operators (<5 times a year), for 15% (>5 times a year), impossible for 36% of the operators. For AVB3 nonresponsive to isoproterenol occurring during the night, a temporary pacing lead (TPL) is implanted by: the on-site medical staff on-duty (27%), the on-call interventional cardiologist (21%), the on-call electrophysiologist (19%), a permanent pacemaker is implanted by the electrophysiologist (12%), the strategy is not standardized (15%). An externalized active fixation lead (AFL) for AVB3 has already been implanted by 50% of the operators. 80 (86%) have already observed a dislocation of the TPL, a cardiac perforation already occurred in 57 (61%), a groin hematoma in 35 (38%), and this technique was proscribed for 4% of the operators.

CONCLUSION

Our survey shows important disparities in terms of management of AVB3 among the different centers. An externalized AFL with a reusable generator was used by half of the centers.

[COV IMPACT: Stress exposure analysis among hospital staff in 2 hospitals in France during the COVID-19 pandemic]

The COVID-19 pandemic has swept through our hospitals which have had to adapt as a matter of urgency. We are aware that a health crisis of this magnitude is likely to generate mental disorders particularly affecting exposed healthcare workers. Being so brutal and global, this one-of the kind pandemic has been impacting the staff in their professional sphere but also within their private circle. The COV IMPACT study is an early assessment survey conducted for 2 weeks in May 2020, of the perception by all hospital workers of the changes induced in their professional activity by the pandemic. The study was carried out by a survey sent to the hospital staff of Béziers and Montfermeil. The readjusted working conditions were source of increased physical fatigue for 62 % of the respondents. Moral exhaustion was reported by 36 %. It was related to the stress of contracting the infection (72 %) but above all of transmitting it to relatives (89 %) with a broad perception of a vital risk (41 %). This stress affected all socio-professional categories (CSP) and was independent of exposure to COVID. Change in organisation, lack of information and protective gear and equipment were major factors of insecurity at the start of the epidemic. Work on supportive measures is necessary. It should focus on the spread of information, particularly towards the youngest, as well as bringing more psychological support and a larger amount of medical equipment, beyond healthcare workers and the COVID sectors.

[ICD and left ventricular assist device interference: Case report]

Left ventricular assist devices are used for severe chronic heart failure management. Many of these patients have an implantable cardioverter defibrillator (ICD). However electromagnetic interferences are possible between the 2 devices. We report here a case of an interference in a 77 years-old patient. This was associated with an impossibility to communicate with the ICD. We discuss how to manage this situation.

Radiation exposure during cardiac device implantation: Lessons learned from a multicenter registry

BACKGROUND

Little data are available about radiation exposure during cardiac electrical device implantation, and no dose reference levels have been published. This multicenter, prospective, observational study assesses patient and staff radiation exposure during cardiac device implantations, and aims at defining dose reference levels.

METHODS

Patient demographic, procedural, and radiation data were obtained for 657 procedures from nine institutions. Physician and staff exposure were measured using real-time dosimeters worn beneath and above lead apron. Statistical analysis included fluoroscopy time (FT), dose-area product (DAP), and DAP adjusted for FT and body mass index.

RESULTS

Pacemakers and cardioverter defibrillators were implanted in 481 and 176 patients, respectively. Of these, 152 were treated with cardiac resynchronization therapy (CRT). Median FTs were 837s (interquartile range [IQR]: 480-1323), 117s (IQR: 69-209), and 101s (IQR: 58-162), and median DAPs were 1410 (IQR: 807-2601), 150 (IQR: 72-338), and 129 (IQR: 72-332) cGy.cm² for biventricular, dual chamber, and ventricular device implantation, respectively. Dose reference levels correspond to the third quartile values. During CRT, higher exposure was observed with four X-ray systems than with the two newer and customizable ones (adjusted DAP of 0.90 [IQR: 0.26-1.01] and 0.29 [IQR: 0.23-0.39], respectively; P < .001).

CONCLUSION

Based on real-life measurements, this multicenter registry provides dose reference levels and may help centers assess radiation exposure. Although biventricular device implantation was responsible for the highest radiation exposure, FT was meaningfully shortened compared to previously reported values. For a same FT, the use of new generators and custom settings has significantly reduced DAP.

[Current limits of the long duration rhythmic holter: A real life study]

BACKGROUND

Syncope or stroke remain frequently without any explained diagnosis. Long duration holter ECG is an available tool to diagnose arrhythmias. However, this tool is subject to availability of the recorders.

AIM

Report a single center experience with long duration holter ECG in clinical practice, in the different cardiology and neurology indications, and to assess the different delays until achievement of a diagnosis.

METHODS AND RESULTS

The device (Sorin Spiderflash) was used for 48 patients between January 2018 and June 2018. The holter was applied for a mean duration of 10±4days. The mean age was 55+19 years-old. 20 patients (42%) were explored for a stroke or transient ischemic attack (TIA), 18 (36%) for palpitations, 6 (12%) for syncope and 4 (8%) for evaluation of arrhythmias management. An abnormality has been recorded in 11 (22%) patients and a treatment has been administered in 5 patients (10%). Regarding, the timing of the exam, the mean time between the index event and the indication was 39 days. The mean time between the indication and the availability of the device was 32 days. 16 Days was the mean time for lecture and 23 days was the mean time between the result and the appointment with the cardiologist and neurologist.

CONCLUSION

In this registry, the management of patients by non-invasive long duration holter ECG monitoring may be improved regarding the timing of the exams, their lecture and new appointments with the physicians.

[New tools for diagnosis and management of arrhythmias]

If we have more and more ECG's tools for the diagnosis of arrhythmias, it is found that these remain largely unknown and mostly underused. If the use of these new tools is increasing by the cardiologist, it remains largely insufficient by non-cardiologists including neurologists or general practitioners. This article explains the main ECG tools available and discusses their respective indications at a time when things are constantly evolving.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

P1899Heparin and low-molecular-weight heparin switch associated with an increase in bleeding complications in patients on apixaban undergoing catheter ablation: The AMPER ABLATION study

Background

The aim of this study was to identify the factors associated with bleeding complications in patients taking apixaban and undergoing a catheter ablation in everyday clinical practice.

Methods

AMPER ABLATION is a multicenter, observational, prospective study of patients with non valvular atrial fibrillation (AF) undergoing a catheter ablation. Eligible patients had been taking apixaban (2.5 or 5 mg twice daily) for ≥3 weeks before the procedure, and were followed for 30 days afterwards.

Results

A total of 595 patients (65 [interquartile range 59, 72] years, 67% male, mean CHA2DS2-VASc score 1.85±1.37) were enrolled at 25 academic/nonacademic centers in France; 524 patients (88%) were receiving apixaban 10 mg/day and 71 (12%) 5 mg/day. 323 patients (54%) underwent an AF ablation, and 272 (46%) an atrial flutter (AFL) ablation. The most prevalent concomitant disorders were hypertension (51% of patients), diabetes (15%) and vascular disease (10%). Mean creatinine concentration was 1.06±0.28 mg/dL, median weight was 83±18 kg and mean creatinine clearance (Cockcroft-Gault) was 82±34 mL/min. The management of apixaban in the periprocedural period was left to the investigator's preference. Overall, 264 patients were switched to unfractionated heparin or enoxaparin (238 for AF ablations and 26 for AFL ablations). The median duration of switch was 29 hours. Complications were reported at 30 days, and included 12 bleeding events (1 tamponade needing drainage, 1 pericardial effusion without drainage, 7 International Society on Thrombosis and Haemostasis [ISTH] non major bleedings for AF ablations and 1 pericardial effusion without drainage, and 2 ISTH non major bleedings for AFL ablations) and 1 embolic event (non disabling stroke for an AF ablation). Comparing patients with and without a bleeding event revealed a higher rate of heparin or low-molecular-weight heparin (LMWH) switching in patients with a bleeding event (60% vs 35%; p=0.02). A switch to heparin or LMWH was the only factor associated with an increase rate of bleeding (odds ratio 2.5; [CI 95%; 1.1, 7.1]; p=0.01).

Conclusion

Heparin or LMWH switch in the periprocedural AF and AFL-ablation period is associated with an increased rate of bleeding complications at 30 days.

Acknowledgement/Funding

Financial support from BMS

[How to manage anticoagulation in atrial fibrillation ablation]

There are many randomized trials evaluating non-vitamin K oral anticoagulants (NOAC) in patients with atrial fibrillation ablation. VENTURE AF, RE-CIRCUIT, and recently AXAFA have evaluated the three main NOACs in this indication. Other studies such as ABRIDGE J and AEIOU complemented these results. The management of the anticoagulation in these patients is one of the subjects of the European Society of Cardiology guidelines, as well, as, the EHRA guide recently released. The purpose of this article is to summarize published studies and guidelines.

[Diagnosis of arrhythmias on memories of pacemakers and defibrillators: Practical management]

Pacemakers and defibrillators have holter capabilities that can record episodes of arrhythmias. Different studies evaluated the effect on the risk of strokes of different durations of arrhythmias. The question of the management of patients depending on the duration of the arrhythmia episode is addressed in this article depending on the duration of the episode and the arrhythmia burden.

[Epidemiology of early repolarization pattern in Maghreb]

An early repolarization variant (ERV) in inferolateral leads has recently been associated with vulnerability to ventricular fibrillation. These studies have been conducted in the occidental countries. The prevalence of ERV in the population of the Maghreb is unknown. The aim of this study was to evaluate the prevalence and risk factors of ERV in a young population from Algeria.

METHODS

We assessed the prevalence of ERV within a population of 441 healthy subjects (mean age 25 years) using 12-lead electrocardiography. ERV was stratified by three independent cardiologists according to the J-point elevation (≥0.1mV) in the inferior, apicolateral or both leads with QRS slurring or notching.

RESULTS

The inferolateral ERV pattern was present in 55 subjects (12.4%). A malign ERV (>2mm) was present in 5 subjects (9% of ER) and ER in inferior and lateral leads in 40% of ER. An ERV pattern was more frequently associated with young age, male, bradycardia and T wave in V1 lead.

CONCLUSION

An ERV is a common finding in a healthy Algerian young population. This prevalence seems to be more important than other studies due to young age and not to a racial difference. Our population were more at risk that other studies, and we found more T waves in V1 lead in this people, due to an ethnic particularities or a phenotypic association with the Brugada syndrome.

[Asymptomatic Brugada syndrome: From diagnosis to treatment]

Brugada syndrome management may be a difficult question. This article reviews diagnosis, prognosis evaluation, current and investigated treatments.

Perioperative management of antithrombotic treatment during implantation or revision of cardiac implantable electronic devices: the European Snapshot Survey on Procedural Routines for Electronic Device Implantation (ESS-PREDI)

The European Snapshot Survey on Procedural Routines for Electronic Device Implantation (ESS-PREDI) was a prospective European survey of consecutive adults who had undergone implantation/surgical revision of a cardiac implantable electronic device (CIED) on chronic antithrombotic therapy (enrolment March-June 2015). The aim of the survey was to investigate perioperative treatment with oral anticoagulants and antiplatelets in CIED implantation or surgical revision and to determine the incidence of complications, including clinically significant pocket haematomas. Information on antithrombotic therapy before and after surgery and bleeding and thromboembolic complications occurring after the intervention was collected at first follow-up. The study population comprised 723 patients (66.7% men, 76.9% aged ≥66 years). Antithrombotic treatment was continued during surgery in 489 (67.6%) patients; 6 (0.8%) had their treatment definitively stopped; 46 (6.4%) were switched to another antithrombotic therapy. Heparin bridging was used in 55 out of 154 (35.8%) patients when interrupting vitamin K antagonist (VKA) treatment. Non-vitamin K oral anticoagulant (NOAC) treatment was interrupted in 88.7% of patients, with heparin bridging in 25.6%, but accounted for only 25.3% of the oral anticoagulants used. A total of 108 complications were observed in 98 patients. No intracranial haemorrhage or embolic events were observed. Chronic NOAC treatment before surgery was associated with lower rates of minor pocket haematoma (1.4%; P= 0.042) vs. dual antiplatelet therapy (13.0%), VKA (11.4%), VKA + antiplatelet (9.2%), or NOAC + antiplatelet (7.7%). Similar results were observed for bleeding complications (P= 0.028). Perioperative management of patients undergoing CIED implantation/surgical revision while on chronic antithrombotic therapy varies, with evidence of a disparity between guideline recommendations and practice patterns in Europe. Haemorrhagic complications were significantly less frequent in patients treated with NOACs. Despite this, the incidence of severe pocket haematomas was low.

Early Detection and Treatment of Atrial Arrhythmias Alleviates the Arrhythmic Burden in Paced Patients: The SETAM Study

BACKGROUND

Remote monitoring (RM) can remotely detect atrial tachyarrhythmias (ATAs). The benefit of RM compared to conventional follow-up in the detection and management of ATA was assessed in recipients of dual-chamber pacemakers.

METHODS

The multicenter randomized SETAM study enrolled 595 patients in sinus rhythm with a CHA₂ DS₂ -VASc score ≥2, without ATA history and untreated with antiarrhythmics and antithrombotics, randomly assigned to RM (RM-ON; n = 291) versus ambulatory follow-up (RM-OFF; n = 304) during 12.8 ± 3.3 months. ATA occurrence, burden, and management were analyzed together with adverse clinical events.

RESULTS

Patients were 79 ± 8 years old, 63% men, with a CHA₂ DS₂ -VASc score of 3.7± 1.2. ATA were detected in 83 patients (28%) in the RM-ON versus 66 (22%) in the RM-OFF group (P = 0.06). The median time between the pacemaker implantation and the first treated ATA was 114 days [44; 241] in the RM-ON versus 224 days [67; 366] in the RM-OFF group (hazard ratio [HR] = 0.56; 95% confidence interval [CI]: 0.37-0.86; P = 0.01). Therapies for ATA were initiated in 92 patients and the time to treatment of ATA was shortened by 44% in the RM-ON group (HR = 0.565; 95% CI: 0.37-0.86; P = 0.01). Over the last 4 months of follow-up, the mean ATA burden was alleviated by 4 hours/day (18%) in the RM-ON group. The rate of adverse clinical events was similar in both groups.

CONCLUSION

Remotely monitored patients were diagnosed and treated earlier for ATA, and subsequently had a lower ATA burden.

Safety of device implantation under antipatelet therapy with ticagrelor: About 20 cases

INTRODUCTION

Management of antiplatelet therapy at the time of device implantation remains controversial. This study aimed to assess the risk of bleeding complications in patients receiving ticagrelor at the time of cardiac device surgery.

METHODS

We performed a multicentre (N=4), retrospective study from January 2015 to January 2016. The survey included all patients (pts) treated with ticagrelor before undergoing pacemaker, implantable-cardioverter defibrillator (ICD) implantation or generator replacement. We report haemorrhagic post-procedural complications at 1 month. A significant bleeding complication was defined as pocket hematoma requiring a surgical evacuation or prolonged hospitalization, hemothorax, pericardial effusion or tamponade.

RESULTS

A total of 20 patients underwent a permanent pacemaker or ICD implantation while taking a combination of antipatelet therapy with ticagrelor and aspirin. The mean age of the patients was 65±9 years, 95% were male, 25% of patients were diabetics, 55% had hypertension and 50% presented a history of heart failure. All the patients had a history of acute coronary syndrome (6 [4-26] months before the procedure). The majority of implanted devices were ICDs (17, 85%) with 5 single chamber, 4 dual chambers and 9 triple chambers ICDs. Subclavian venous approach was utilized in 9 patients. The mean duration of procedure was 60minutes. One per-procedure bleeding was described due to high venous pressure, without post-procedure hematoma. A post-procedure pocket hematoma has been experienced by one patient. The subclavian approach was used for the 2 patients. No blood transfusion was needed for these 2 cases.

CONCLUSION

Ticagrelor treatment at the time of heart rhythm device procedures does not seem to be associated with an increased risk of significant bleeding complications. In our study, 2 patients experienced non significant bleeding complications.

[Cardiac permanent pacemaker after transcatheter aortic valve implantation: A predictive and scientific review]

Transcatheter aortic valve implantation (TAVI) is nowadays a worldwide technique in the field of treating aortic stenosis. One of the main side effects linked to the technique are mostly attached to rhythm disturbances, such as atrioventricular (AV) and intraventricular blocks. Consequently, a pacemaker implantation is often required. That implantation rate is estimated between 8 and 30%, depending on the valve chosen. Thanks to main meta analysis on the subject, it has been managed to isolate the following risks factors for AV block development: preoperative right bundle branch block (RBBB: the most powerful element), complete AV block during the procedure, male gender, a so-called porcelain aorta, the absence of previous valvular surgery, the aortic annulus size (i.e when that size is inferior to the valve's one) and the QRS duration after the procedure (the superior threshold has been set at 128ms for the Corevalve). The currently recommendations advice to implant a pacemaker are as followed: high grade AV block (in the main studies, the implantation occurs within the 5 days after the TAVI), complete and transient AV block during the TAVI, second degree AV block and RBBB associated with first degree AV block. Our article aims to review the arrhythmic issues of TAVI.

Once-daily rivaroxaban for long-term stroke prevention in patients with atrial fibrillation

Oral anticoagulation is the long-term standard of care for preventing stroke in patients with atrial fibrillation (AF). However, anticoagulation is associated with an increased risk of bleeding, such that its use should be based on the absolute risks of stroke and bleeding, and the relative benefit-risk profile of the individual patient. Non-vitamin K antagonist oral anticoagulants, including rivaroxaban, are alternatives to vitamin K antagonists such as warfarin in this setting, and are supported in treatment guidelines as the optimal choice for patients with AF at moderate to high risk of stroke. Rivaroxaban can be given in fixed doses without routine coagulation monitoring, and phase III studies have demonstrated its safety profile and efficacy in patients with non-valvular AF, including the elderly and those with co-morbidities. Moreover, rivaroxaban is administered once daily, which has advantages for optimal patient adherence to medication over the long term. The established efficacy and safety profile of rivaroxaban, together with its convenient once-daily dosing schedule, may contribute to improved patient outcomes and lead to sustained benefits for patients with non-valvular AF at risk of stroke.

[Non-vitamin K oral anticoagulants and cardioversion]

Direct oral anticoagulants are now frequently used in patients experiencing atrial fibrillation. Some of these patients may need a cardioversion. How to manage the procedure in these patients? Can we perform the procedure in patients taking the direct oral anticoagulant? Should we switch the treatment to a vitamin K antagonist? When do we need to perform a transesophageal echocardiography? All these questions justify this review article.

[Platypnea-orthodeoxia syndrome: A case of hypoxemia associated with a patent foramen ovale]

Platypnea-orthodeoxia syndrome is a rare disease characterized by dyspnea and oxygen desaturation in the upright position with improvement in the supine position. We report a case of an 87-year-old woman with a recent history of traumatic hip, spine deformity and vertebral compression fracture, referred due to dyspnea oxygen desaturation. Thoracic tomodensitometry excluded the diagnosis of pulmonary embolism. Transthoracic echocardiography, with intravenous administration of agitated saline contrast solution, revealed the presence of atrial septal defect associated with a right to left shunting and mild enlargement of aortic root. Surgical closure of atrial septal defect resulted in resolution of the syndrome.

[Free floating thrombus in right cardiac chambers and thrombolysis]

Free-floating thrombi in the right heart chambers is a rare phenomenon. Nearly 99% of detected cases are associated with the presence of proven pulmonary embolism. Its presence is associated with a poor outcome with a mortality between 27 to 44% according to studies. Despite the emergency of treatment, optimal management of free floating right heart thrombus remains controversial with no clear consensus. We present the case of a 84-year-old man hospitalised for acute decompensated heart failure. After an initial favourable evolution, a degradation of respiratory occurred with dyspnea and desaturation. A bedside transthoracic echocardiography showed a mobile serpiginous thrombus, 7cm size, moving to and across the tricuspid valve. A computed tomography of the chest demonstrated massive bilateral pulmonary embolism. After persistence of the thrombus and seven days of heparinotherapy, thrombolysis therapy was initiated. The thrombus disappeared 24h after thrombolysis. Without contra-indication, thrombolysis is a faster, readily available treatment for the management of floating thrombus in the right heart chambers associated with pulmonary embolism.

Patients' attitude and knowledge about oral anticoagulation therapy: results of a self-assessment survey in patients with atrial fibrillation conducted by the European Heart Rhythm Association

The purpose of this European Heart Rhythm Association survey was to assess the attitude, level of education, and knowledge concerning oral anticoagulants (OACs) among patients with atrial fibrillation (AF) taking vitamin K antagonists (VKAs), non-VKA oral anticoagulants (NOACs) or antiplatelets. A total of 1147 patients with AF [mean age 66 ± 13 years, 529 (45%) women] from 8 selected European countries responded to this survey. The overall use of OACs and antiplatelets was 77 and 15.3%, respectively. Of the patients taking OACs, 67% were on VKAs, 33% on NOACs, and 17.9% on a combination of OACs and antiplatelets. Among patients on VKAs, 91% correctly stated the target international normalized ratio (INR) level. The proportion of patients on VKA medication who were aware that monthly INR monitoring was required for this treatment and the proportion of patients on NOAC who knew that renal function monitoring at least annually was mandatory for NOACs was 76 and 21%, respectively. An indirect estimation of compliance indicated that 14.5% of patients temporarily discontinued the treatment, and 26.5% of patients reported having missed at least one dose. The survey shows that there is room for improvement regarding education and adherence of patients taking OACs, particularly regarding monitoring requirements for NOACs.

New oral anticoagulants in patients undergoing atrial flutter radiofrequency catheter ablation: an observational study

AIM

Atrial flutter (AFL) ablation requires optimal periprocedural anticoagulation in order to minimize thromboembolic events/bleeding risk. This study describes the characteristics of patients receiving new oral anticoagulants before AFL ablation and assesses complications.

METHODS

This multicenter, retrospective study reports ischemic and hemorrhagic predischarge, postprocedural complications.

RESULTS

We evaluated 60 patients (62.3% male; mean age: 69.2 ± 9.7 years; CHA2DS2-VASc score: 2.44 ± 1.46, HAS-BLED score: 1.14 ± 0.7). Twenty-one (35.0%) and 23 patients (38.3%) received twice-daily dabigatran 110 or 150 mg; 16 patients (26.6%) received once-daily rivaroxaban (15 mg [n = 5] or 20 mg [n = 11]). Four cases of postprocedural minor bleeding were reported.

CONCLUSION

This is the first study assessing new oral anticoagulants for periprocedural anticoagulation, specifically in patients undergoing AFL ablation. No major bleeding was reported. Further prospective investigation is warranted.