Pacemaker or ICD and MRI: is MRI safety the new standard?

Recently new models of cardiac pacemakers have been commercialised. Some of these models have the particularity to be compatible with MRI (they are called MRI safe). The safety of the MRI for the patients implanted depends on the device it self and the lead(s). These review article focuses on the benefits and limits of these new devices. A practical guideline is proposed for patients implanted by a pacemaker or ICD and undergoing MRI.     

Use of 64-slice tomodensitometry after cardiac arrest

Acute coronary occlusion is the leading cause of out-of-hospital cardiac arrest, so patients are usually referred for immediate coronary angiography and angioplasty. We report here the observation of such a patient who previously underwent a coronary artery bypass intervention and who had a difficult arterial access. Moreover, the nature of the grafts was unknown (saphenous and/or mammary arteries). Multi-slice cardiac tomo-densitometry was performed rather than a conventional coronary angiography and it allowed the analysis of native arteries and grafts. There was no stenosis and angioplasty was unnecessary.     

Management of cardiac arrhythmias during pregnancy

Introduction

Pregnancy can precipitate or exacerbate cardiac arrhythmias. Management of those arrhythmias is not very different from that in non-pregnant women.

Objective

In this review we tried to specify factors which favour arrhythmias in pregnant women and to show their specific management.

Methods

We carried out a search through PubMed using as keywords: pregnancy, cardiac arrhythmias, antiarrhythmics.

Results

Hemodynamic perturbations, direct electrophysiological effects of hormones and underlying heart disease are potential factors that can promote arrhythmias in pregnancy. Usually, no drug therapy is needed for the management of supraventricular or ventricular premature beats but potential promoting factors should be eliminated. In paroxysmal supraventricular tachycardia, vagal maneuvers should be tried firstly. Adenosine could be used if vagal maneuvers are ineffective. In pregnant women with atrial fibrillation, the goal of treatment is the conversion to sinus rhythm or the control of ventricular rate. Ventricular arrhythmias are usually uncommon during pregnancy and often occur in the absence of structural heart disease and are responsive to drug therapy. Symptomatic bradycardia rarely complicates pregnancy and its management does not differ from that in non-pregnant women.     

Cavernous haemangioma of the right atrium

Cardiac haemangiomas are rare benign primitive tumors. We are reporting the case of a 67-year-old woman presenting with a haemangioma of the right atrium. This tumor was discovered by echocardiography because of cerebral strokes. The magnetic resonance imaging determined the characteristics of the tumor. It was completely resected through a right atrial approach. This was a round mobile mass, pediculed and implanted at the inferior area of the interatrial septum. The histopathological analysis revealed a cavernous haemangioma.     

The coronary patient six months after cardiac rehabilitation: rehabilitation evaluation research (RER study)

Aims of the study

The aims of the study are to elaborate and test, in a coronary population admitted in a cardiac rehabilitation (CR) department, an evaluative method 6 months after a cardiac rehabilitation programme, with emphasis on modified cardiac risk factors.

Patients and methods

Every coronary patient admitted in the CR department in Machecoul between 2007 October and 2009 October, who's home were not over 50 km far away and without mental inability, were included. At the start of the programme, he was suggested to complete the training course by a phone interview at 3 months and a multidisciplinary consult at 6 months. It used dietary and physical activity questionnaires, and a 6-minute walk test (6mnWT).

Results

Two hundred and two patients were included (mean age 63,4 ± 10 years, 93% men), 17% after an acute coronary syndrome, 23% after angioplasty and 75% after coronary artery bypass graft. The cardioprotective dietary score increased from 7.8 ± 4.3 to 12.7 ± 3 (on a scale from –17 to +19) and the physical activity score from 15.4 ± 7.7 to 19.5 ± 4.8 (on a scale from 5 to 40). The 6mnWT increased in CR (from 431 ± 90 m to 511 ± 91 m) and was maintained at 6 months (513 ± 88 m). The European recommendation goals were achieved by 76% of patients for LDL (< 1 g/L), 64% for blood pressure (< 140/90), 82% for a BMI less than 30 and 36% a BMI less than 25, 67% central obesity (< 102 cm by men and 88 cm by women) and 82% for no smoking. Four non-fatal cardiac events and seven vascular events were reported by a mean delay of 190 ± 30 days.

Conclusion

A six monthly evaluation of CR programme can be used in a cardiac rehabilitation department routinely activity.     

Detection of induced myocardial ischemia during stress cardiovascular magnetic resonance

In the past decade, cardiovascular magnetic resonance (CMR) has evolved considerably. Its clinical applications enable the diagnosis and prognostic assessment of patients with ischemic heart disease. CMR is safe, with absence of any ionizing radiation, and offers the greatest information from a single test, allowing the assessment of myocardial morphology, myocardial function and viability. Stress-CMR can be used for detection and quantification of ischemia. This article analyses the technical approach, the limits and reviews the available literature about diagnostic performance of stress CMR testing and its results in the prognostication of cardiac patients. With further improvements in CMR techniques and the establishment of a standardized study protocol, stress-CMR will play a pivotal role in managing patients with ischemic heart disease.     

Tumeur thyroïdienne ectopique dans le ventricule droit du cœur

The intracardiac ectopic thyroid tumour is rare. We report the case of a woman who was admitted for exertional dyspnea. The echocardiography revealed an obstructive tumor in the right ventricular outflow tract. Histological examination of the removed tumour showed the ectopic follicular thyroid tissue.     

Pénétration de l’approche radiale dans le monde et apprentissage de la technique

The transradial approach has been used for the first non selective coronary angiographies but was quickly replaced by the femoral approach until a new birth in 1989 for coronary angiography in 1989 and coronary angioplasty in 1992. Transradial approach use is extremely heterogeneous in the world, dominated by some countries in Europe, Canada, and eastern Asia (India, Taiwan, China, Japan).Risk factors of failure have been well described, allowing two kinds of learning: systematic attempt in all kind of patients when working with a proctor; patient selection when beginning the technique alone in order to get a high and stable success rate from the beginning. Systematic radial approach for coronary angiography is a must to learn the technique.     

Outcome in AN adult patients: a 13-year follow-up in 484 patients

Background

To study the long-term prognosis of anorexia nervosa (AN), 484 adult AN patients were followed on a mean duration of 13 years.

Results

The mortality rate was 1.2%. Eight factors were linked to the lack of recovery at 2 years: low BMI at discharge, low energy and fat intakes, high drive for excessive exercising, high score for perfectionism, for interpersonal distrust and for anxiety, use of tube-feeding and adhesion to treatment (P < 0.02). Four factors explained the risk of the binge/purging form at 2 years: having had binge-eating disorder and overweight before AN, having had purging episodes within the first 2 years of AN; having had very high energy intakes through meals and being not treated by tube-feeding. During the 13-year follow-up, very few binge/purging patients turned out to have the restrictive form. Two main factors explained 67% of the variance of menses recovery: having a BMI > 18.5 kg/m²; and having no physical hyperactivity. The recovery rate increased with the elapsing of relapse-free time (P = 0.02). After a 13.5-year follow-up, 292 out of the 484 patients were recovered (60.3%), 25.8% had a relatively good outcome, 6.4% a bad outcome and 6.4% a severe outcome. Very few factors were identified as predictors of a good outcome (binge-eating/purging subtype, personality disorder).     

Associated factors for sleep apnea in heart failure

Objective

Genesis of sleep apnoea syndrome (SAS) in chronic heart failure (CHF) is not well known. The aim of our study was to find associated factors to SAS in heart failure (HF) and to look for differences between central sleep apnea (CSA) and obstructive sleep apnea (OSA).

Patients and methods

We realised a cross-sectional and retrospective study. Thirty patients with stable heart failure under medical optimal therapy were included. Polygraphy, echocardiography and cardiopulmonary exercise were systematically performed.

Results

Men were predominant (80%) in the group. Mean age, left ventricular ejection fraction (LVEF) were respectively 64.1 ± 13.8 years and 40 ± 9.8%. SAS was present in 60% of patients (33.3% were classified as central sleep apnoea [CSA] and 26.7% as obstructive sleep apnoea [OSA]). Body mass index, blood pressure and left ventricular pressures estimated by the E/Ea ratio were significantly higher in the group with SAS (P < 0.05) compared to the non SAS group. New York Heart Association class was significantly higher (P = 0.04) and the predicted peak VO₂ was significantly lower in CSA patients compared to OSA patients.

Conclusion

High left ventricular pressures estimated by the E/Ea are significantly associated with SAS in heart failure. CSA patients tend to have a worse functional state than OSA patients.     

Antiplatelet agents increase hemorrhagic risk in patients undergoing a cardiac pacemaker or ICD implantation

Objectives

This study was designed to assess the hypothesis that the implantation or the replacement of a cardiac stimulator or defibrillator in patients receiving antiplatelet agents is associated with an increase of the haemorrhagic risk in comparison with patients not receiving antiplatelet agents (control group).

Methods and results

We retrospectively included all the patients undergoing pacemaker or ICD implantation or replacement between January 2007 and May 2010. The primary criterion was the incidence of bleeding complications. In our center, 685 patients were implanted in this period. Two hundred and fourteen (31%) were implanted while taking antiplatelet agents, including 164 (24%) taking aspirin, 31 (4%) taking clopidogrel and 19 (3%) taking the combination aspirin plus clopidogrel, while 471 patients (69%) did not receive antiplatelet agents. The primary criteria was the hemorrhagic complications. Complications were noted in 14 patients out of 471 (3%) not taking antiplatelet agents, in 16 patients out of 214 (7.5%) taking an antiplatelet agent (P = 0.004). The complications concerned 13 patients out of 164 taking aspirin (7.9%), one patient out of 31 (3.2%) taking clopidogrel and two patients out of 19 taking the combination aspirin plus clopidogrel (10.5%) (P = 0.042 for aspirin vs placebo, NS for all other comparisions). In multivariable analysis, the factors associated with an increase of the heamorrhagic complications were the type of implant (ICD) (OR 3,7; P = 0.001) and antiplatelet treatment (OR 2,7; P = 0.009).

Conclusion

Pacemaker and ICD implantation or replacement in patients taking antiplatelet agents are associated with an increase of the hemorrhagic risk.     

Accessory pathway ablation in children: indications and results

Introduction

Radiofrequency ablation of accessory pathways (AP) has become a first-line treatment, except in young children where the indications are discussed because of radiation risks and complications of catheterization. The purpose of the study was to evaluate the indications and results of radiofrequency AP ablation in children and teenagers.

Methods

Electrophysiological study (EPS) was performed in 145 patients aged from 5 to 18 years (13.5 ± 3) with a preexcitation syndrome (PS).

Results

AP ablation was indicated in 66 children (group 1); others represent the group I. Group I was older and less frequently asymptomatic. All children with a spontaneous malignant form had an ablation. Group 1 has a faster conduction through the AP than group 2. The induction of reentrant tachycardia (RT), atrial fibrillation and the presence of a malignant form is more common in group 1. Failures or reappearances of WPW after ablation were frequent (20, 26%) related to a younger age (15 ± 3 vs 17 ± 4) (< 0.05). In group 2, one 18-year-old teenager with untreated RT died before ablation. Asymptomatic children are well with disappearance of PS in two. Medically treated symptomatic children are well.

Conclusion

If spontaneous malignant forms, symptoms with drugs or practice of competitive sport are indications of AP ablation, it is recommended to wait for adolescence in other children.