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Archives of cardiovascular diseases
Volume 111, n° 5
pages 317-319 (mai 2018)
Doi : 10.1016/j.acvd.2018.04.002
Received : 3 April 2018 ;  accepted : 3 April 2018
Scientific editorial

New data on resynchronization, ablation, anticoagulation, an assist device and athletes’ electrocardiograms: A mosaic of updates
Nouvelles données sur la resynchronisation, l’ablation, l’anticoagulation, un dispositif d’assistance et l’électrocardiogramme de l’athlète: une mosaïque de mises à jour
 

Jean-Yves Le Heuzey a, b,
a Paris Descartes University, Paris, France 
b Cardiology Department, European Georges-Pompidou Hospital, 75015 Paris, France 

Département de cardiologiehôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France

Keywords : Atrial fibrillation, Direct oral anticoagulant, Resynchronization, Arrhythmology, Surgery

Mots clés : Fibrillation atriale, Anticoagulants oraux directs, Resynchronisation, Rythmologie, Chirurgie

Abbreviations : DOAC


This special arrhythmology issue of Archives of Cardiovascular Diseases presents several papers that update interesting topics in the field of arrhythmias. The issue includes three papers on interventional arrhythmology and surgery (cardiac resynchronization therapy; the Heartmate II™ device [Saint-Jude Medical, Saint-Paul, MN, USA]; and ablation of atrial fibrillation); it also contains three papers on anticoagulation in patients with atrial fibrillation (the design of the PAROS study with apixaban; the relationship between the concentration of von Willebrand factor and cardiovascular risk; and persistence of anticoagulant treatment in patients seen in primary care). The final paper concerns training-induced changes in the electrocardiograms of football players.

In the paper by Binda et al. [1], it is clear that significant secondary mitral regurgitation, despite cardiac resynchronization therapy, provides important prognostic information beyond left ventricular reverse remodelling. Nevertheless, further studies are needed to evaluate the potential role of new percutaneous procedures for mitral valve repair in improving the outcome of these very high-risk patients. It is likely that major developments of these percutaneous procedures will allow such analyses to be obtained in the future. The goal, of course, is to increase the proportion of responders to cardiac resynchronization therapy.

The paper by Corre et al. [2] deals with the electrical storms often observed in patients implanted with a left ventricular assist device (the Heartmate II™ device in this study). The authors analysed the early postoperative phase (<30 days). Electrical storms were defined as three or more separate episodes of sustained ventricular arrhythmia within a 24-hour interval. It appears that electrical storm is common and pejorative in the early postoperative period. It is interesting to consider the possibility of radiofrequency ablation therapy in case of intractable arrhythmia.

The third paper on interventional arrhythmology concerns atrial fibrillation ablation. Bacquelin et al. [3] propose a novel method for localization and ablation of conduction gaps after wide antral circumferential ablation of pulmonary veins. After this large ablation, if pulmonary vein isolation is not achieved, the atria are paced using an ablation catheter. For each pacing site, the activation delay and activation sequence were analysed using a circular mapping catheter positioned at the pulmonary vein ostium. The conclusion of the authors is that this simple pacing method accurately detects the location of residual connection after the lesion sets performed for atrial fibrillation ablation, allowing pulmonary vein isolation to be achieved. Given the relatively high proportion of patients in whom ablation is a failure because of reconnection of pulmonary veins, this technique seems to be interesting and promising.

Three publications in this issue deal with anticoagulation in atrial fibrillation. The first concerns the PAROS study; Picard et al. [4] describe the rationale and design of this cross-sectional study, set in France, in patients with non-valvular atrial fibrillation. The results of the PAROS study will soon be available, providing “real-life” data on disease characteristics, comorbidities and treatment history. Subgroup analyses are being performed according to anticoagulant (apixaban, other direct oral anticoagulants [DOACs], vitamin K antagonists) and previous experience with anticoagulation treatment. Bivariate and multivariable analyses are being performed, first to identify characteristics statistically associated with the choice of newly initiated anticoagulant treatment. Many data are now available on “real-life” treatment with DOACs. Apixaban was the third DOAC to be launched on the market and, to date, observational data from everyday clinical practice are less numerous than those reported for dabigatran and rivaroxaban. It is important to collect these data to analyse the profile of the patients treated with this anticoagulant. However, it is not possible to make valuable comparisons between the different DOACs. The only scientific means of making such comparisons would be in randomized trials designed to compare one drug with another. The various comparisons that have been made between these drugs, taking into account the “real-life” data–even if they have been made by the health authorities of different countries–have no real scientific value. Randomized trials facilitating direct comparisons are needed.

The paper from Ancédy et al. [5] deals with a rarely studied coagulation factor: von Willebrand factor. The study clearly shows that high plasma concentrations of von Willebrand factor may discriminate patients with non-valvular atrial fibrillation at greater risk of stroke or all-cause death. This point has not been completely explored in many trials involving DOACs.

The third paper on anticoagulation concerns the initiation and continuation of oral anticoagulant prescriptions for stroke prevention in non-valvular atrial fibrillation. The data are from a cohort study in primary care in France [6]. Persistence is certainly a key point in the treatment of atrial fibrillation, and for its success in stroke prevention. We know that a high proportion (probably 20–30% of patients) will stop their anticoagulant treatment. Collings et al. observed that non-persistence (treatment discontinuation or switch) with vitamin K antagonists was lower than with rivaroxaban and dabigatran. However, non-persistence with the newest drug, apixaban, was similar to that for vitamin K antagonists. Larger studies with longer follow-up periods are needed to support these findings. The data were collected between January 2014 and January 2016; it is likely that the situation has changed since then because, during the first years of prescription, these new drugs were not very well known by general practitioners. Consequently, the prescribers were very cautious, and probably stopped some of these treatments, sometimes influenced by media campaigns.

Finally, the last and very interesting paper concerns electrocardiographic training-induced changes in a large series of football players. Huttin et al. [7] analysed these changes in 2484 elite male football players from the French professional football league. Initial and serial annual electrocardiogram monitoring over subsequent years allowed the authors to investigate the long-term effect of exercise on cardiac conduction and electrophysiological remodelling. The most frequent outliers were subjects with electrical left ventricular hypertrophy and sinus bradycardia. The authors consider that these results have important implications for optimizing electrocardiogram interval measurements in the initial screening and during follow-up of football players, with potential cost-effective implications. It is clear that such studies may have important consequences for the decisions made by the medical staff of elite teams, knowing the importance of these decisions in medicolegal and economic terms.

Funding

None.

Disclosure of interest

Fees (modest) for boards and conferences: Bayer, BMS/Pfizer, Boehringer Ingelheim, Mylan, Servier.

References

Binda C., Menet A., Appert L., and al. Time course of secondary mitral regurgitation in patients with heart failure receiving cardiac resynchronization therapy: Impact on long-term outcome beyond left ventricular reverse remodelling Arch Cardiovasc Dis 2018 ;
Corre J., Picard F., Garcia R., and al. Electrical storm in the early phase of HeartMate ((R)) II device implantation: incidence, risk factors and prognosis Arch Cardiovasc Dis 2018 ;
Bacquelin R., Martins R.P., Behar N., and al. A novel method for localization and ablation of conduction gaps after wide antral circumferential ablation of pulmonary veins Arch Cardiovasc Dis 2018 ;
Picard F., Ducrocq G., Danchin N., and al. Apixaban in the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation in France: rationale and design of the PAROS cross-sectional study Arch Cardiovasc Dis 2018 ;
Ancedy Y., Berthelot E., Lang S., and al. Is von Willebrandt factor associated with stroke and death at mid-term in patients with non-valvular atrial fibrillation? Arch Cardiovasc Dis 2018 ;
Collings S.L., Vannier-Moreau V., Johnson M.E., and al. Initiation and continuation of oral anticoagulant prescriptions for stroke prevention in non-valvular atrial fibrillation: a cohort study in primary care in France Arch Cardiovasc Dis 2018 ;
Huttin O., Selton-Suty C., Venner C., Vilain J.B., Rochecongar P., Aliot E. Electrocardiographic patterns and long-term training-induced time changes in 2484 elite football players Arch Cardiovasc Dis 2018 ;



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