Background/Aims: Long-term mechanical assist devices are now commonly used in the treatment of severe heart failure to unload the failing ventricle, maintain sufficient end-organ perfusion and improve functional capacity. Depending on the assisted ventricles, 3 categories of long-term assist devices are available: left ventricular assist device (LVAD), bi-ventricular assist device and total artificial heart. Improvements in technology, especially the advent of smaller, durable continuous flow pumps, have led to the use of LVADs in a much broader population of patients in the last 10 years. Both the number of patients living with LVADs and the life expectancy of these patients are increasing. Regarding this growing number of patients with LVAD, intensivists need to understand the physiology of the devices, their functioning, potential complications and their management. Methods: We performed a narrative review of relevant medical literature regarding the physiology of patients with LVAD and management of common complications relevant to the critical care physicians. Results: The most frequent complications occurring in the LVAD patients after the post-operative period are bleeding, driveline infections, thrombosis, device malfunction, right ventricular failure and arrhythmias. Bleeding is the most frequent adverse event in LVAD due to a combination of anticoagulation and acquired von Willebrand disease secondary to shear stress produced within the pump. Their management includes antiplatelet therapy arrest, reduction of the anticoagulation regimen and specific therapy if feasible. Infection is the second most common cause of death after cardiac failure in LVAD patients. All infections must be aggressively treated to avoid seeding the device. Device thrombosis can develop even when patients are adequately anticoagulated and taking antiplatelet therapy because the LVAD is responsible for a chronic hypercoagulable state. Conclusion: Management of these unique patients in the ICU is best accomplished with a multidisciplinary team that includes specialists in advanced heart failure, LVAD nurse coordinators and intensivists. (C) 2018 S. Karger AG, Basel

Background/Aims: Long-term mechanical assist devices are now commonly used in the treatment of severe heart failure to unload the failing ventricle, maintain sufficient end-organ perfusion and improve functional capacity. Depending on the assisted ventricles, 3 categories of long-term assist devices are available: left ventricular assist device (LVAD), biventricular assist device and total artificial heart. Improvements in technology, especially the advent of smaller, durable continuous flow pumps, have led to the use of LVADs in a much broader population of patients in the last 10 years. Both the number of patients living with LVADs and the life expectancy of these patients are increasing. Regarding this growing number of patients with LVAD, intensivists need to understand the physiology of the devices, their functioning, potential complications and their management. Methods: We performed a narrative review of relevant medical literature regarding the physiology of patients with LVAD and management of common complications relevant to the critical care physicians. Results: The most frequent complications occurring in the LVAD patients after the post-operative period are bleeding, driveline infections, thrombosis, device malfunction, right ventricular failure and arrhythmias. Bleeding is the most frequent adverse event in LVAD due to a combination of anticoagulation and acquired von Willebrand disease secondary to shear stress produced within the pump. Their management includes antiplatelet therapy arrest, reduction of the anticoagulation regimen and specific therapy if feasible. Infection is the second most common cause of death after cardiac failure in LVAD patients. All infections must be aggressively treated to avoid seeding the device. Device thrombosis can develop even when patients are adequately anticoagulated and taking antiplatelet therapy because the LVAD is responsible for a chronic hypercoagulable state. Conclusion: Management of these unique patients in the ICU is best accomplished with a multidisciplinary team that includes specialists in advanced heart failure, LVAD nurse coordinators and intensivists.

Sur des modèles animaux d’hibernation, lorsque la FEVG est significativement diminuée, on retrouve systématiquement des plages de nécrose histologique. Notre hypothèse est qu’une zone de nécrose est toujours visible sur l’IRM en cas de FEVG ≤ 45 % si l’origine est ischémique. Une étude pilote rétrospective semble confirmer cette affirmation, et CAMAREC va tester cette hypothèse de façon prospective. Le PHRC-National CAMAREC a pour objectif d’évaluer la performance diagnostique de l’IRM cardiaque dans la recherche d’une cause ischémique à une dysfonction systolique sans cause évidente. Nous allons inclure 406 patients avec découverte récente d’une FEVG ≤ 45 % sans cause évidente, pendant 2 ans dans 9 centres français (1re inclusion datée de mai 2018). Chez tous les patients, une IRM cardiaque puis une coronarographie seront pratiquées, et seront relues par des comités de relecture indépendants en aveugle. Une première étude ancillaire médicoéconomique s’attachera à comparer les coûts de 2 stratégies : une dans laquelle la coronarographie n’est réalisée que si de la nécrose est observée à l’IRM, l’autre dans laquelle la coronarographie est pratiquée chez tous les patients. Une seconde étude ancillaire évaluera l’intérêt du T1-mapping dans cette population. Le résultat principal est l’évaluation de la sensibilité de l’IRM cardiaque pour prédire une coronaropathie expliquant une dysfonction VG systolique récente. L’étude médicoéconomique évaluera les économies d’une stratégie dans laquelle la coronarographie n’est pas réalisée systématiquement. Si la capacité de l’IRM cardiaque à éliminer une cause ischémique en cas de dysfonction systolique se confirme, la nouvelle stratégie proposant une coronarographie uniquement en cas de nécrose vue sur l’IRM pourra être proposée en pratique courante.

ABSTRACT Background and objective Dyspnoea in pulmonary embolism ( PE ) remains poorly characterized. Little is known about how to measure intensity or about the underlying mechanisms that may be related to ventilatory abnormalities, alveolar dead space ventilation or modulating factors such as psychological modulate. We hypothesized that dyspnoea would mainly be associated with pulmonary vascular obstruction and its pathophysiological consequences, while the sensory‐affective domain of dyspnoea would be influenced by other factors. Methods We undertook a prospective study of 90 consecutive non‐obese patients (mean ± SD age: 49 ± 16 years, 41 women) without cardiorespiratory disease. All patients were hospitalized with symptoms for <15 days and a confirmed PE (multi‐detector computed tomography ( MDCT ) scan, n = 87 and high‐probability ventilation/perfusion scan, n = 3). Patients underwent assessment of dyspnoea using the Borg score, modified Medical Research Council ( mMRC ) scale, assessment of psychological trait, state of anxiety and depression and chest pain via the Visual Analogical Scale at the time of maximum dyspnoea. Functional evaluations such as the quantitative ventilation–perfusion lung scan, echocardiography, alveolar dead space fraction and tidal ventilation measurements were completed within 48 h of admission. Results Multivariate analyses demonstrated that dyspnoea was mainly linked to pulmonary vascular obstruction and/or its consequences such as raised pulmonary arterial pressure and chest pain. The sensory‐affective domain of dyspnoea showed additional determinants such as age, depression and breathing variability. Conclusion Dyspnoea is mainly related to vascular consequences of PE such as increased pulmonary arterial pressure or chest pain. The sensory‐affective domain of dyspnoea also correlates with age, depression and breathing variability.

Background: A feature tracking (FT) was designed to simultaneously extract myocardial strains in main cardiac chambers from cine MRI images. Its inter-observer and scan-rescan reproducibility was assessed and sample sizes required to detect predefined longitudinal changes in strain values were provided. Method: FT was applied on left (LV) and right (RV) ventricles as well as left atrium (LA) of 21 individuals (66 10 years) who underwent 2 Mills 2 weeks apart. Global peaks for radial, circumferential, longitudinal strains, radial motion fraction (Mr), fractional area change (FAG) and tricuspid annular plane excursion (TAPSE) were estimated. Inter-operator and inter-exam reproducibility were evaluated using coefficients of variations (CV) and intra-class correlation coefficients (ICC). Results: Reproducibility of all measurements were good to excellent for inter-operator (LV:CV<6.5%, ICC>0.91; RV:CV<12%, ICC>0.86; LA:CV<14%, ICC>0.85) and inter-study (LV:CV<15%, ICC>0.65; RV:CV<20%, ICC>0.71; LA:CV<20.5%, ICC>0.83) evaluations. Reasonable sample sizes are required to detect a longitudinal difference of 10-15% in strain values (LV:5 to 33 individuals, RV:14 to 62 individuals, LA:4 to 65 individuals). Conclusions: FT-based functional evaluation of main heart chamber deformation from cine MRI is repeatable and thus suitable for follow-up. Strain measurements may help for the joint clinical evaluation of LV, RV or LA implication in various cardiomyopathies.

Objective To perform a head-to-head comparison of coronary CT angiography (CCTA) and dobutamine-stress echocardiography (DSE) in patients presenting recent chest pain when troponin and ECG are negative. Methods Two hundred seventeen patients with recent chest pain, normal ECG findings, and negative troponin were prospectively included in this multicenter study and were scheduled for CCTA and DSE. Invasive coronary angiography (ICA), was performed in patients when either DSE or CCTA was considered positive or when both were non-contributive or in case of recurrent chest pain during 6month follow-up. The presence of coronary artery stenosis was defined as a luminal obstruction >50% diameter in any coronary segment at ICA. Results ICA was performed in 75 (34.6%) patients. Coronary artery stenosis was identified in 37 (17%) patients. For CCTA, the sensitivity was 96.9% (95% CI 83.4–99.9), specificity 48.3% (29.4–67.5), positive likelihood ratio 2.06 (95% CI 1.36–3.11), and negative likelihood ratio 0.07 (95% CI 0.01–0.52). The sensitivity of DSE was 51.6% (95% CI 33.1–69.9), specificity 46.7% (28.3–65.7), positive likelihood ratio 1.03 (95% CI 0.62–1.72), and negative likelihood ratio 1.10 (95% CI 0.63–1.93). The CCTA: DSE ratio of true-positive and false-positive rates was 1.70 (95% CI 1.65–1.75) and 1.00 (95% CI 0.91–1.09), respectively, when non-contributive CCTA and DSE were both considered positive. Only one missed acute coronary syndrome was observed at six months. Conclusions CCTA has higher diagnostic performance than DSE in the evaluation of patients with recent chest pain, normal ECG findings, and negative troponine to exclude coronary artery disease.

Importance of left atrial (LA) phasic function evaluation is increasingly recognized for its incremental value in terms of prognosis and risk stratification. LA phasic deformation in the pathway of normal aging has been characterized using echocardiographic speckle tracking. However, no data are available regarding age-related variations using feature-racking (FT) techniques from standard cine magnetic resonance imaging (MRI). We studied 94 healthy adults (41 ± 14 yr, 47 women), who underwent MRI and Doppler echocardiography on the same day for left ventricular (LV) diastolic function evaluation. From cine MRI, longitudinal strain and strain rate, radial motion fraction, and radial relative velocity, respectively, corresponding to the reservoir, conduit, and LA contraction phases, were measured using dedicated FT software. Longitudinal strain and radial motion fraction decreased gradually and significantly with aging for both reservoir ( r > 0.31, P < 0.003) and conduit ( r > 0.54, P < 0.001) phases, whereas they remained unchanged during the LA contraction phase. Subsequently, the LA contraction-to-reservoir ratio increased significantly with age ( r > 0.44, P < 0.001). Longitudinal strain rate and radial relative velocity significantly decreased with age (reservoir: r = 0.39, P < 0.001, conduit: r > 0.54, P < 0.001), and these associations tended to be stronger in women than in men. Finally, associations of LA functional indexes with age were stronger in individuals with lower transmitral early-to-atrial maximal velocity ratio and mitral annulus maximal longitudinal velocity, as well as higher transmitral early maximal-to-mitral annulus maximal longitudinal velocity ratio, highlighting the LV-LA interplay. Age-related changes in LA phasic function indexes were quantified by cine MRI images using a FT technique and were significantly related to age and LV diastolic function.

PurposeValvuloarterial impedance (ZVA), estimating left ventricle (LV) afterload, has been proposed in transthoracic echocardiography (TTE) as a predictor of mortality in aortic valve stenosis (AVS). However, its calculation differs from arterial characteristic impedance (ZC). Our aim was to apply the concept of ZC calculation to estimate ZVA from MR with carotid tonometry and to evaluate these indices through their associations with symptoms, LV diastolic function and aortic stiffness.Materials and MethodsIn 40 patients with AVS (76 ± 13 years), ZVA‐TI derived from velocity time integral and E/Ea were estimated by TTE. ZVA‐INS, based on ZC formula, calculated as the instantaneous pressure gradient to peak flow ratio and aortic compliance were estimated by using MRI at 1.5 Tesla.ResultsBoth ZVA estimates were higher in symptomatic than asymptomatic patients (707 ± 22 versus 579 ± 53 dyne.s/cm5, P = 0.031 for ZVA‐INS and 4.35 ± 0.16 versus 3.33 ± 0.38 mmHg.m2/mL, P = 0.018 for ZVA‐TI). Although they were both associated with aortic compliance (r = ‐0.45; P = 0.006 for ZVA‐INS and r = ‐0.43; P = 0.008 for ZVA‐TI) only ZVA‐INS was associated with E/Ea (r = 0.50; P < 0.001). In multivariate analysis to identify determinants of E/Ea, a model including age, mean blood pressure, LV ejection fraction, LV mass, and aortic valve area was performed (R2 = 0.41; P < 0.01). When ZVA‐INS was added to the model, its overall significance was higher R2 = 0.56 (P < 0.01) and ZVA‐INS and LV mass were the only significant determinants.ConclusionZVA‐INS was more strongly associated with diastolic dysfunction than usual parameters quantifying AVS severity. This new ZVA estimate could improve LV afterload evaluation.Level of Evidence: 1J. Magn. Reson. Imaging 2017;45:795–803.

Although few studies demonstrated the ability of MRI dynamic anatomical sequences to assess right ventricular (RV) diastolic function, no data are available for velocity-encoded MRI (VE-MRI). Accordingly, our aim was to evaluate RV diastolic function from VE-MRI, as compared to reference Doppler echocardiography. We studied 109 healthy individuals (67 men, age: 42±15 years) who underwent RV Doppler echocardiography and MRI, on the same day. VE-MRI images were analyzed using custom software, providing: tricuspid flow early peak velocity (E,cm/s) and flow-rate (Ef,ml/s), atrial peak velocity (A,cm/s) and flow-rate (Af,ml/s), longitudinal myocardial early peak velocity (E'). Same velocity parameters were extracted from Doppler echocardiography (E, A, E/A, E', E/E'). Despite the fair associations between MRl and echocardiographic indices, the highest correlation with age was obtained for MRI flow-rate ratio Ef/Af (r=O. 60). Associations with age for velocity ratios (E/A) were equivalent for MRI and echocardiography (r=0.41). Automatically extracted PC-MRI tricuspid inflow parameters were strongly related to age. These associations were comparable to echocardiography for maximal velocities ratio and were stronger when considering peak flow-rates ratio.

Background. - Right ventricular failure (RVF) is a major cause of morbidity and mortality in left ventricular assist device (LVAD) recipients.Objectives. - To identify preoperative echocardiographic predictors of post-LVAD RVF.Methods. - Data were collected for 42 patients undergoing LVAD implantation in Germany. RVF was defined as the need for placement of a temporary right ventricular assist device or the use of inotropic agents for 14 days. Data for RVF patients were compared with those for patients without RYE A score (ARVADE) was established with independent predictors of RYE by rounding the exponentiated regression model coefficients to the nearest 0.5.Results. - RYE occurred in 24 of 42 LVAD patients. Univariate analysis identified the following measurements as RVF risk factors: basal right ventricular end-diastolic diameter (RVEDD), minimal inferior vena cava diameter, pulsed Doppler transmitral E wave (Em), Em/tissue Doppler lateral systolic velocity (S-LAT) ratio and Em/tissue Doppler septal systolic velocity (S-SEPT) ratio. Em/S-LAT >= 18.5 (relative risk [RR] 2.78, 95% confidence interval [CI] 1.38-5.60; P=0.001), RVEDD >= 50 mm (RR 1.97, 95% CI 1.21-3.20; P=0.008) and INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) level 1 (RR 1.74, 95% CI 1.04-2.91; P=0.04) were independent predictors of RYE An ARVADE score > 3 predicted the occurrence of post-implantation RYE with a sensitivity of 89% and a specificity of 74%.Conclusion. - The ARVADE score, combining one clinical variable and three echocardiographic measurements, is potentially useful for selecting patients for the implantation of an assist device. (C) 2015 Elsevier Masson SAS. All rights reserved.

Background To assess the relationship between the presence of myocardial interstitial fibrosis as reflected by the increase in native T1 values and alterations in left ventricular (LV) diastolic function evaluated by phase contrast cardiac magnetic resonance (PC-CMR), in subjects with severe aortic valve stenosis (AVS). Methods We studied 20 subjects (71±10 years) with severe AVS including 19 with a preserved ejection fraction. All patients underwent transthoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) exams. CMR included conventional LV systolic function and delayed enhancement evaluations as well as a native T1 mapping acquisition using the modified Look-Locker inversion recovery sequence and velocity encoding data of the transmitral inflow for the evaluation of LV diastolic function. These latter CMR data were analyzed using custom software resulting in segmental T1 values and diastolic parameters such as transmitral peak velocities (E, A), peak flow rates (Ef, Af), filling volume (FV), and myocardial peak velocities. Results For all patients, TTE revealed the presence of severe AVS according to ESC criteria (aortic valve area indexed to BSA= 0.43±0.09 cm2/m2 and mean gradient 54 ±14mmHg). When compared to CMR data of 34 elderly controls (60±8 years) despite the preserved ejection fraction (patients=66±10%; controls=66±4%), diastolic parameters indicated an impaired LV relaxation in patients with severe AVS. Importantly, while dense fibrosis volume quantified from delayed enhancement images was not related to diastolic function parameters, a significant relation was found between native myocardial T1 values and parameters of LV filling such as: the ratio between the peak filling rate and the peak atrial rate EfMR/AfMR (r=0.51; p<0.05); the ratio between the peak atrial rate and the filling volume Af/FVMR (r=0.67; p<0.05); and the peak atrial rate Af (r=0.63; p<0.05). Conclusions Interstitial myocardial fibrosis assessed non-invasively by native T1 is related to the severity of diastolic dysfunction in subjects with severe AVS.

Our objectives were to assess the ability of phasecontrast MRI (PC-MRI) to detect sub-clinical age-related variations of left ventricular (LV) diastolic parameters and thus to provide age-related reference ranges currently available for echocardiography but not for MRI-PC, and to identify independent associates of such variations.

Objectives: We investigated the impact of inodilators on the accuracy of E/e′ ratio as a surrogate for pulmonary artery occlusion pressure in patients with decompensated end-stage systolic heart failure. Setting: The ratio of early diastolic transmitral flow velocity to tissue Doppler mitral annular early diastolic velocity, E/e′, and pulmonary artery occlusion pressure have been shown to be correlated. The validity of E/e′ for predicting pulmonary artery occlusion pressure in patients with decompensated end-stage systolic heart failure was recently challenged, but the influence of inodilators was not taken into account, despite the reported influence of these drugs on left ventricular relaxation properties. Patients and Intervention: Invasive hemodynamic monitoring and echocardiographic data were collected prospectively from 39 patients with decompensated end-stage systolic heart failure (92% male), aged 56 ± 13 years. These patients had dilated ventricles with a low cardiac index (1.9 ± 0.6 L/min/m2) and high pulmonary artery occlusion pressure (22 ± 8 mm Hg), and 90% required inodilator support during hospitalization. Measurements and Main Results: The correlation between septal E/e′ and pulmonary artery occlusion pressure was good for examinations in the absence of inodilators (n = 21) (r = 0.7; p < 0.001), but no correlation was found when inodilators were used (n = 31). Lateral and mean E/e′ were poorly correlated with pulmonary artery occlusion pressure, if at all, in both cases. Conclusions: By modifying ventricular relaxation properties and the influence of filling pressure on e′, inodilator agents severely impair the correlation between E/e′ and pulmonary artery occlusion pressure in patients with decompensated end-stage systolic heart failure.

Poster: ESCR 2014 / 470 / The added value of phase contrast MR in the evaluation of right ventricular diastolic function: comparison to Doppler echocardiography by: N. Kachenoura , E. Bollache, A. Redheuil, S. Clement-Guinaudeau, L. Perdrix, B. Diebold, M. Ladouceur, E. Mousseaux; Paris/FR

By developing a simple general equilibrium structure, this paper compares the welfare effects of tourism specialisation and economic diversification in tourist cities. We discovered that tourist cities with limited carrying capacity easily suffer from side effects, particularly Dutch disease, when faced with rapid tourism growth. Therefore, such cities should actively use revenue that is generated from the booming tourism sector to pursue economic diversification for the sake of sustainable urban development.

Ventricular assist devices (VADs) have become an established therapeutic option for patients with end-stage heart failure. The appearance of heart failure in VAD patients seems unexpected. Nevertheless, this phenomenon is not rare. We report six cases of VAD patients with clinical presentation of heart failure at different times after implantation and describe the mechanisms involved. The aetiology of this heart failure, like its clinical presentation, varies and has yet to be identified.

Heart failure constitutes an important medical, social and economic problem. The prevalence of heart failure is estimated as 2–3% of the adult population and increases with age, despite the scientific progress of the past decade, especially the emergence of natriuretic peptides, which have been widely used as reliable markers for diagnostic and prognostic evaluation. Identification of new reliable markers for diagnosis, analysis, prognosis of mortality and prevention of hospitalization is still necessary. Galectin-3 is a soluble β-galactoside-binding protein secreted by activated macrophages. Its main action is to bind to and activate the fibroblasts that form collagen and scar tissue, leading to progressive cardiac fibrosis. Numerous experimental studies have shown the important role of galectin-3 in cardiac remodelling due to fibrosis, independent of the fibrosis aetiology. Galectin-3 is significantly increased in chronic heart failure (acute or non-acute onset), independent of aetiology. Some clinical studies have confirmed the predictive value of galectin-3 in all-cause mortality in patients with heart failure. In our review, we aim to analyse the role of galectin-3 in the development of heart failure, its value in screening and clinical decision making and its possible predictive application in follow-up as a “routine” test in an addition to established biomarkers, such as B-type natriuretic peptide and N-terminal prohormone of B-type natriuretic peptide.