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Introduction The non-invasive assessment of left ventricular (LV) filling and LA pressure in patients with aortic stenosis (AS) remains challenging. The aim of our study was to identify the echocardiographic parameters that may predict elevated pulmonary capillary wedge pressures (PCWP) measured by cardiac catheterization in patients with severe AS without other valve disease. Methods and results From January 2010 to December 2012, we included 85 consecutive patients with severe AS scheduled for clinically indicated cardiac catheterization study. Comprehensive transthoracic echocardiography (TTE) was performed in all patients within 24 hours of the hemodynamic study. Mean age was 75±9 years, 65% of them were male, 65%, 22% and 54% had respectively a history of hypertension, diabetes, and dyslipidemia. NYHA functional class was ≥III in 63% of patients. By TTE, mean LV ejection fraction, max left atrial (LA) volume indexed, were respectively 60±9%, and 38±16mL/m 2 . Mean mitral septal E/e’ ratio was 18.6±9. Cardiac catheterization found 60% cases of coronary artery disease and the mean PCWP was 13.5±7mmHg. As compared to patients with low PCWP (<13mmHg), those with higher PCWP had similar LVEF, and AS severity but significantly higher LA indexed volume (41±19 vs. 29±10mL/m 2 , p=0.004) and septal E/e’ (22.4±10 vs. 14.7±5, p=0.001). A maximal LA indexed volume >29ml/m 2 predicted a PCWP>13mmhg with a sensitivity of 77% and a specificity of 62% (area under the curve=0.73). Similarly, mitral annular septal E/e’ >12 predicted PCP>13mmHg with a sensitivity of 90% and a specificity of 60% (area under the curve=0.73). Conclusion In severe AS patients, maximal LA indexed volume >29/ml/m 2 and E/e’ ratio >12, derived from TTE, appear as good markers of elevated PCWP. Further studies are needed to investigate their prognostic values. [ABSTRACT FROM AUTHOR]

Background The global left ventricular (LV) hemodynamic afterload as assessed by valvulo arterial impedance (Zva), may be an independent predictor of mortality in patients with severe aortic stenosis (AS) and preserved LV ejection fraction (LVEF). However, its quantification using echocardiography may be subject to error measurement. The aim of this study is to determine the prevalence and impact on long-term survival of high Zva, purposely measured by cardiac catheterization. Methods and results 768 patients with preserved LVEF (>50%) and severe AS (valve area ≤1cm²) underwent cardiac catheterization. Zva was derived from catheterization data and calculated using validated formula. Zva was considered high when >5 mmHg/ ml/m 2 . Overall, high Zva was found in 42% of all AS patients. Patients with high Zva were significantly older (p<0.0001), and more often female (p< 0.0001), they had significantly smaller aortic valve area (p<0.0001), higher mean gradient (p=0.001), lower indexed stroke volume (p<0.0001) and cardiac output (p<0.0001), significantly higher LVED filling pressures (p=0.03), systolic pulmonary artery pressure (p=0.0005), higher capillary wedge pressure(p=0.006), reduced systemic arterial compliance (p<0.0001), but higher systemic vascular resistances(p<0.0001). Ten-year survival was significantly reduced in patients with higher Zva (50±5%) as compared to those with lower Zva (67±3%; p=0.01). After adjustment for all other risk factors, Zva was independently associated with reduced long-term survival (hazard ratio [HR] =1.12 95% CI: 1.009-1.22; p=0.03). Of interest, high Zva remains associated with reduced survival as compared to low Zva, in patients with normal LV stroke volume, but was no longer significant in low flow patients (>60mL: 49±8vs. 69±4%, p=0.012; ≤60mL: 49±7 vs. 53±13%, p=0.96). Conclusion In this large cardiac catheterization-based study, high Zva estimated invasively is frequent in patients with severe AS, and appears as a robust and independent predictor of survival. [ABSTRACT FROM AUTHOR]

Background The exact prevalence, characteristics and impact on both short- and long-term outcome of low flow, low gradient severe aortic stenosis (LFLG) despite preserved left ventricular ejection fraction (LVEF), remain debatable. The aim of our study is to describe the outcome of a large group of patients with LFLG AS using cardiac catheterization data. Methods and Results Between 2000 and 2010, 770 patients with preserved LVEF (>50%) and severe AS (valve area <1cm2) without significant other valvular heart disease having underwent cardiac catheterization, were retrospectively analyzed. Mean age was 74±8 years, 42% were female, 46% had associated coronary artery disease. LFLG (indexed LV stroke volume<35 mL/m² and mean pressure gradient<40 mm Hg) were found in 13% of patients (n=99), normal flow/high gradient (NFHG) in 50% (n=388), LFHG in 14% and NFLG in 22%. In comparison with classical patients with NFHG, those with LFLG were significantly older, and more often female. The cardiac cathererization hemodynamic data including the systemic compliance, vascular systemic resistances and the valvulo-arterial impedance were significantly impaired in LFLG patients as compared to those with NF/HG. Thirty-days mortality was higher in patients with LFLG when compared to NFHG (9 vs. 4%, p=0.06) and 10-year survival was significantly reduced in LFLG (32±8%) when compared to NFHG (66±4%; p=0.0005) (figure). Furthermore, after adjustment for confounding factors, multivariate analysis show that LFLG AS was independently associated with reduced long-term survival: HR= 2.02; 95 CI: (1.31-3.15) p=0.002. Patients who underwent AVR had significantly better longterm survival than those who were managed medically (70 pts) (all p< 0.001) in all our 4 groups of severe AS patients irrespective of the gradient or flow. Conclusion Our cardiac catheterization-based study confirms that LFLG severe AS is a frequent entity associated with poor both short- and long-term outcome. Of interest, AVR seems to be a beneficial therapeutic option, even in patients with LFLG pts. [ABSTRACT FROM AUTHOR]

Background The prognostic impact of pulmonary arterial pressure (PAP) remains controversial in aortic stenosis (AS) and few studies focused only on patients with preserved left ventricular ejection fraction (LVEF). We therefore aimed to investigate the impact of PAP, derived from our large catheterization database, on survival in severe AS with preserved LVEF. Methods and results Between 2000 and 2010, 749 patients (74±8y, 57% of males) with preserved LVEF and severe AS without other valvular heart disease underwent cardiac catheterization, including right heart hemodynamic assessment. Pulmonary hypertension (PH) was defined as mean PAP >25mmHg. Systolic and mean PAP were 34.5±12 and 21.9±9mmHg, respectively. Overall, 29% (n=215) of patients had PH, and these patients were significantly older (p<0.0001), with lower LVEF (p<0.0001) and higher heart rate (p=0.016) than those without PH. In addition, they more frequently had, hypertension (p<0.0001), diabetes (p=0.001), coronary artery disease (CAD, p<0.0001) and chronic pulmonary disease (p=0.043). Aortic valve replacement (AVR) was performed in 91% of patients and 30-day mortality was 4.3%, significantly higher in patients with PH (7.7 vs. 3.4%, p=0.014). In logistic regression analysis, after adjustment for age, gender, LVEF, CAD and mean transaortic pressure gradient, mean PAP was an independent predictor of increased 30-day mortality (OR=1.06, 95% CI: 1.02-1.1, p=0.004). Overall long-term survival was significantly reduced in patients with PH as compared to those without PH (10-year survival: 41±8 vs. 61±3%, p<0.0001). In multivariate analysis, after adjustment for all cofactors, PH was an independent predictor of mortality (HR=1.5, 95% CI: 1.1-2.1, p=0.037). Conclusion In patients with severe AS and preserved LVEF, PAP is an independent predictor of both 30-day and long-term mortality. In order to improve the prognosis of these patients, AVR could be considered before the occurrence of severely elevated PAP. [ABSTRACT FROM AUTHOR]

Purpose Despite public campaigns for calling rapidly the emergency phone number in case of chest pain, many patients still delay their call. We sought to determine factors influencing the call delay in case of STEMI. Methods We studied 206 consecutive patients admitted for STEMI. They were classified according to tertiles of delay between symptoms onset and the first call (« early-callers » for 1st & 2nd tertiles, « late-callers » for the 3rd tertile). We compared these 2 groups according to the registry data. We contacted the survivors to obtain further information on socio-economic status and events during symptoms onset. Results The patients (age 64±14 y, 75% males) called on average in 2.5±3.5 hours (early-callers 1.6±1.8 vs. 4.4±5.0 for late-callers). In multivariate analysis, the following factors were significantly associated with late call: age (OR=1.03, 95%CI: 1.00-1.05), living >30 min. from cath lab (OR=2.8, 1.1-7.1), symptoms onset between 00:00-05:59 am (OR=2.3, 1.1-4.8) and first call to the family physician (OR=1.9, 1.8-3.6). The respondents to interview did not differ from others regarding age and call delay. Main variables during interview are compared between in the 2 groups in Figure. In a second model using interview variables, following factors were associated with late call, adjusted for age and sex: symptoms onset between 00:00-05:59 am (OR=3.8, 1.00-14.5), self-medication (OR=7.7, 2.2-27.0), mild pain (visual scale <6: OR=10.0, 2.94-33.3) and symptoms onset out of home (OR=6.7, 1.04-50.0). We found no association between call delay and education level, occupation, cardiovascular risk factors and history. Conclusions Delayed call for STEMI is multifactorial. Our data are useful to target the population and highlight messages in future campaigns. Abstract 0227 – Figure: Comparison of early vs. late callers [ABSTRACT FROM AUTHOR]

Background Previous studies suggested that a low flow defined as an indexed stroke volume (SVi) < 35 ml/m 2 may be an important determinant of outcome in patients with severe aortic stenosis (AS). However, its quantification using echocardiography may be subject to error measurement. The aim of this study is to determine the impact of low SVi determined during cardiac catheterization on long-term survivalamong patients with severe aortic stenosis and preserved LV ejection fraction. Methods and results Between 2000 and 2010, 768 patients with preserved LVEF (>50%) and severe AS (valve area ≤1cm²) without other valvular heart disease underwent cardiac catheterization. SVi was derived from catheterization data. Mean age was 74±8 years, 42% were female, 46% had coronary artery disease and mean LVEF was 72±10%. Overall, low SVi was found in 27% (n=...) of AS patients. As compared to patients with normal SVi, those with decreased SVi were significantly older (p<0.0001) and had more frequently atrial fibrillation (p<0.0001) in addition, they had lower LVEF (p=0.04),; aortic valve area (p<0.0001), mean pressure gradient (p= 0.001), systemic arterial compliance (p<0.0001) and higher-systemic vascular and pulmonary resistances (p<0.0001). Ten-year survival was significantly reduced in patients with lower SVi as compared to those with normal SVi (41±5% vs. 63±3%; p=0.0007, Figure). After adjustment for all other risk factors, SVi was independently associated with long-term survival (hazard ratio =0.97, 95%CI: 0.95-0.99; p=0.01). Conclusion Low SVi measured invasively is frequent in patients with severe AS and preserved LVEF and is a powerful and independent predictor of survival. SVi should be systematically measured and used as an additional parameter for risk stratification of patients with severe AS. [ABSTRACT FROM AUTHOR]

Introduction Chest pain is a frequent cause of admission to the emergency department (ED). The diagnosis and medical care of acute coronary syndrome (ACS) with ST-segment elevation (ST+ ACS) are more standardized than non ST-segment elevation ACS (NST ACS). There is very few series on patients classified as low ACS-diagnosis probability. We aimed to assess the 1-year outcome of patients admitted for chest pain in ED and discharged with low risk of ACS. Methods This restrospective study included all patients admitted in the ED of University Hospital Center of Limoges between January and March 2013 for chest pain, without ST-segment elevation and normal troponin level. Patients’ characteristics and initial diagnosis were collected in ED records. Final diagnosis was obtained by phone one year later, from general practitioners or alternatively directly from the patients themselves. Results Among the 244 patients studied, 38 (15.6%) were lost during follow-up. Mean age was 50±17 years, 58% being males. Among the 41% of cases in whom the initial diagnosis (i.e. ED discharge) was modified during follow-up, 9% (n=8) were diagnosed with coronary disease, and 38% (n=32) with panic attack. Major adverse cardiac events rate was 2.4% (n=5) in the whole population, and 60% of them were directly discharged to home. In the ED, the detection of a cardiovascular etiology of chest pain was accurate with good specificity (96%) but lower sensibility (61%). Of note, the rate of false negative patients was 8.5%. Conclusion Low probability NST SCA diagnosis is complex in the ED and may frequently lead to erroneous diagnosis associated with therapeutic delay. Nevertheless, cardiac disorders are uncommonly misdiagnosed. A systematic, individualized and close monitoring after ED discharge is mandatory. [ABSTRACT FROM AUTHOR]

Background: Primary systemic amyloidosis (AL) is a severe plasma cell disorder characterized by amyloid fibrils extracellular deposition in different organs. Myocardial involvement is frequent and has major impact on prognosis. Echocardiography (TTE) is the most common test performed when cardiac involvement is suspected. We hypothesized that a simple measurement of left atrium enlargement (LA) by TTE may provide an important risk marker for this disease. Methods and results: Between 1997 and 2010, 109 patients were diagnosed with systemic AL and had first TTE within 21 days. Patients were mainly treated with conventional chemotherapy (M-Dex) with new agents for refractory or relapsing patients We retrospectively collected demographic baseline characteristics along with biological and echo data of these patients. Mean age was 63±11 years; 58% were male; 24% had hypertension. Mean left ventricular ejection fraction and mean LV wall thickness were respectively 62±13% and 13±3mm. Mean follow up time was 2.42±2 years. None had significant valvular heart disease. LA enlargement was defined by M mode as > 40mm in male and > 36mm in female. Patients with enlarged LA were more often male, slightly older (p=0.05) and with slightly more hypertension (p=0.07) but had significantly lower ejection fraction and more hypertrophied LV walls (All P<0.05). At 5 years, survival rate was markedly reduced in patients with enlarged LA vs. those with normal LA: 31±10% vs.75±7% (P=0.001). By multivariate analysis, after adjusting for age, gender, LVEF, LV wall thickness and presence of hypertension, LA enlargement remained an independent predictor of overall mortality at five years (P=0.03). Conclusion: In patients with systemic AL amyloidosis, LA enlargement, a surrogate marker of diastolic dysfunction and elevated LV filling pressure, is a powerful independent predictor of long-term mortality. Therefore LA enlargement may help to enhance risk stratification in patients presenting with this disease. Display Omitted [Copyright &y& Elsevier]

Implantable cardioverter defibrillaror (ICD) is the gold standard therapy for patients at high risk for ventricular tachyarrhythmias in secondary and primary prevention. Patients with an ICD implanted for primary or secondary prevention were selected from a single-center registry between Jan99-Dec 08. 359 pts (312 men, age 63±12.4years) received consecutively 432 ICD. Among them 217 (60%) have an ischemic heart disease. It was a primary indication in 30% and a secondary in 70% of cases.72 pts (22%) received one or more appropriate shock and 27% efficacy antitachycardia pacing. Secondary indication (RR=7,8; 95%CI: 2,63-23,25), treatment with amiodarone (RR=2.5; 95%CI: 1.34-4.99) and low left ventricular ejection fraction LVEF (<30%) (RR=1.9; 95% CI: 1.02-3.64) predicted appropriate shock occurrence. There were 63 deaths. Heart failure is the major event for hospitalization and remained the predominant mode of death. Predictors of mortality in multivariate modeling included LVEF, increasing age and the use of another treatment than beta-blocker single use. One or more appropriate shock seems to promote the mortality. During the follow up, complication occurred in 33% of cases: one or more inappropriate shock n =58 (16%), 36 leads dislodgment, 28 haematomas, 8 infections, 7 leads failure, 4 device failure, 2 pneumothorax, 2 subclavian thrombosis and 7 others. Prior atrial fibrillation (RR=2.2; 95% CI: 1.12-4.32) and a secondary indication (RR=2.83; 95% CI: 1.27-6.30) predicted inappropriate shock occurrence. The incidence of inappropriate interventions was not dependent on the type of ICD (VVI vs. DDD). Conclusions: Infection can be the most important complication, leading to the system removal. Inappropriate ICD shocks are common adverse consequences that may impair quality of life, may cause hospitalizations and limit cost-effectiveness. Preventive measures are required to optimize quality of life of patients with ICD. [Copyright &y& Elsevier]