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Transcatheter aortic valve replacement or TAVR has become the gold standard for the treatment of symptomatic and severe aortic valve stenosis in elderly patients. Although the role of computed tomography imaging was initially limited to the determination of the optimal vascular approach, it has progressively matured to become the pilar of TAVR work-up while being standardized by consensus conferences. The list of evaluated elements includes aortic annulus diameter, the optimal projection curve, the number of aortic leaflets, the severity and localization of calcifications, coronary ostial height, membranous septum length and aortic angulation. The proper and cautious evaluation of these elements may help evaluating the risk for the main periprocedural complications such as coronary obstruction, annular rupture, permanent pacemaker implantation or procedural failure and selecting the optimal transcatheter heart valve and its size, according to the patient's specific anatomy. In this review, we detail how the evaluation of these parameters may impact the selection of the transcatheter heart valve.

Aortic stenosis is a complex heart disease that involves the aortic valve and the left ventricle. Impairment of the left ventricle, abnormalities in its size, systolic and diastolic function determine the postnatal outcomes in the same way as the aortic valve. In the most severe forms, the left ventricle cannot provide systemic circulation at birth and the physiology is that of hypoplastic left heart syndrome. Fetal aortic valvuloplasty has been developed in the 90s to prevent in utero progression of aortic stenosis to hypoplastic left heart syndrome. In the present article, the most recently reported data about indications, procedure details and postnatal outcomes were reviewed.

Coronary catheterization after transcatheter aortic valve implantation (TAVR) may be challenging. The main objective of the study is to assess the feasibility of coronary catheterization and angioplasty according to each type of valve.We retrospectively studied coronary angiography or percutaneous angioplasty procedures after TAVR in two different centers. The catheterization success of coronary artery was evaluated according to the quality of engagement in ostium and opacification of the artery. Other indicators were collected including catheters used, fluoroscopy and angiography times, DAP and the volume of the contrast agent.Among 1512 TAVR procedures, 33 patients were included. The Sapien 3® valve was implanted in 22 patients and the Evolut® in 11 patients (7 Evolut-R® and 4 Evolut Pro®). Coronary angiography with selective or partially selective catheterization has been successfully performed in all patients with a Sapien 3® valve. In the Evolut® group we identified 3 cases of non-selective catheterization for the right coronary and 1 case for the left coronary. Standard Judkins catheters seem to be the most suitable for both types of valve with very good efficiency.The results of our study is promising for the future of TAVR with a coronary catheterization success rate close to 100% with some difficulties for the Evolut® supra-annular valves. Special attention should be paid to the technique of implantation and orientation of cups in the aortic sinus.

Aortic stenosis remains one of the most frequent valvulopathy worldwide, burdened with great mortality and morbidity, and for which there is not yet an effective preventive approach, although the pathophysiological mechanisms involved in its development are better understood nowadays. Its cure, however, has been revolutionized in the last decade by the advent of transcatheter aortic valve implantation, or TAVI (also named transcatheter aortic valve replacement or TAVR). The technique of TAVI has been refined and its indications has been extended, following the publication of large randomized controlled trials where it was compared to surgical aortic valve replacement with favorable results. Consequently, transfemoral TAVR has become the first line of treatment in case of symptomatic severe aortic valve stenosis. In this review, we describe the pathophysiological mechanisms leading to severe aortic stenosis and the main ongoing randomized controlled trials targeting them. We describe the indication for surgical or percutaneous aortic valve replacement and the main complications following the procedure.

Interventional cardiology is increasingly being offered to frail elderly people thanks to significant technical progress. Transcatheter aortic valve implantation allows the treatment of aortic stenosis by implanting an aortic bioprosthesis through a catheter, without surgery. The left atrial appendage occlusion limits the risk of ischemic stroke in patients with atrial fibrillation who have a contraindication to anticoagulants. These procedures remain invasive and must be proposed after multidisciplinary consultation.

Since trans-catheter valve implantation (TAVI) has emerged for severe symptomatic aortic stenosis treatment, infective endocarditis (IE) appears as a rare but severe complication. Like surgical aortic valve remplacement infective endocarditis (SAVR-IE), TAVI-IE has a noxious impact on morbidity and mortality. Compared to SAVR-IE, TAVI-IE present some similarities as well as differences. Most TAVI-IE occurred during the first year and enterococcus is the more common pathogen. A multimodality imaging approach including echocardiography, multislice computed tomography (CT) and positron emission tomography-CT with blood culture is necessary for the diagnosis. In this high-risk population, the vast majority of TAVI-IE patients are treated with antibiotic therapy alone. Consequently to the expanded indication, the increasing number of TAVI-IE will appear more frequently. If initially only few clinical cases of IE were reported, sparse observational multicenter registries have now been published. Relevant differences were noted on these registries, but some recent publications have provided new informations on IE. The present review reports incidence, symptoms, microbiological profil, risk factors and clinicals outcomes of TAVI-IE. Eventually, we describe the management and the treatment of IE in the context of TAVI.

Eighteen years after the birth of the concept, TAVI (Transcatheter Aortic Valve Implantation) has established itself as the treatment of choice for symptomatic patients with severe aortic valve stenosis at high surgical risk. Unlike surgical prosthesis, the benefit of which has been validated in observational studies, indications for TAVI are now based on the results of large randomized trials. The TAVI revolution continues today with the miniaturization of the equipment, the development of new closure systems, the availability of a wider range of prosthesis sizes and the growing experience of operators, all contributing to the widening of indications to lower risk patients.Dix-huit ans après la naissance du concept, le TAVI («Transcatheter Aortic Valve Implantation») s’est affirmé comme un traitement de choix chez les patients symptomatiques avec rétrécissement valvulaire aortique serré à haut risque chirurgical. Contrairement aux prothèses chirurgicales, dont le bénéfice a été validé dans des études observationnelles, les indications concernant le TAVI s’appuient, aujourd’hui, sur les résultats de larges essais randomisés. La révolution du TAVI continue encore actuellement avec la miniaturisation du matériel, le développement de nouveaux systèmes de fermeture, la disponibilité d’un plus large éventail de tailles de prothèse et l’expérience croissante des opérateurs, le tout contribuant à l’élargissement des indications aux patients à risque intermédiaire.

In 2019, the guidelines on the new entity « chronic coronary syndrome » have been published. They influence importantly the work-up and treatment of patients with stable coronary artery disease. We will also report on publications showing the benefit of percutaneous aortic valve implantation (TAVI) in patients with aortic stenosis and low risk surgical risk. With regard to infectious endocarditis, we elucidate the importance of the vegetation's size for predicting mortality and the prognostic value of the positron emission tomography in predicting septic embolism. We highlight the spectacular results of the DAPA-HF study in patients with heart failure and review publications showing the important role of the detection of myocardial fibrosis and scar by cardiac MRI for risk stratification of sudden cardiac death.L’année 2019 a été marquée par la publication de recommandations sur une nouvelle entité, appelée « syndrome coronarien chronique », qui modifient de manière importante la prise en charge et le traitement des patients avec une maladie coronarienne stable. On relève plusieurs publications démontrant, chez les patients ayant une sténose aortique, et étant à bas risque chirurgical, le bénéfice d’un traitement percutané par rapport à un traitement chirurgical. La prise en charge de l’endocardite a été challengée par deux publications montrant que la taille de la végétation est un facteur de risque de mortalité et la valeur pronostique de la tomographie par émission de positons dans la survenue d’emboles septiques. Nous discutons les résultats spectaculaires de l’étude DAPA-HF dans le domaine d’insuffisance cardiaque et plusieurs études montrant l’intérêt de la recherche de cicatrice myocardique à l’IRM cardiaque dans la stratification du risque de mort subite.

In 2019, the guidelines on the new entity « chronic coronary syndrome » have been published. They influence importantly the work-up and treatment of patients with stable coronary artery disease. We will also report on publications showing the benefit of percutaneous aortic valve implantation (TAVI) in patients with aortic stenosis and low risk surgical risk. With regard to infectious endocarditis, we elucidate the importance of the vegetation's size for predicting mortality and the prognostic value of the positron emission tomography in predicting septic embolism. We highlight the spectacular results of the DAPA-HF study in patients with heart failure and review publications showing the important role of the detection of myocardial fibrosis and scar by cardiac MRI for risk stratification of sudden cardiac death.

International audience; The therapeutic management of aortic stenosis has been drastically changed by the advent of percutaneous valve replacement (TAVI). Since the first implantation, the indications have progressively been extended from the inoperable patient to the patient at low surgical risk. The main objective of this review is to describe the currently recommended main indications of TAVI depending on an individualized assessment of each patient's risk, technical characteristics and anatomical valvular criteria.

Literature concerning transcutaneous symptomatic para valvular cardiac leaks closure (PVLC) after trans aortic valve implantation (TAVI) is relatively scarce. Hereby we present 2 clinical cases, one on an Edwards® Sapien 3 valve and the other one on a Medtronic® Evolut R valve. We present also the preliminary results of the 7 PVLC on TAVI included in our prospective FFPP registry during the 2 first years of enrolment (2017-2018), for a total of 158 inclusions for all valves. Seven procedures were performed on 8 leaks, using a majority of vascular plugs (3 Abbott® Amplatzer Vascular Plugs 2 (AVP2), 3 AVP3, 1 AVP4, and 1 muscular Ventricular Septal Defect (VSD) occluder). All procedures were successful without complication. At 1-month follow-up, all patients became asymptomatic. One-year follow-up was already available for 4 patients: 3 of them were symptoms free, and one-who had a second leak not suitable for PVLC-, underwent a « TAVI in TAVI » procedure 2 months after PVLC. This short experience demonstrates the feasibility, the efficacy and the safety of PVLC on TAVI. We expect to be able to offer more in depth information at the end of our prospective ongoing study.

Valvular disease is the second indication of cardiac rehabilitation (CR) after coronary artery disease. Patients suffering valvular disease are addressed to CR after valvular repair, and are usually old. Valvular replacement are the most frequent, and more and more patients being treated by TAVI are addressed to CR. CR takes place on two phases: From the seventh (day 7) to the fifteenth (day 15) day: management of complications, respiratory physio, and help to autonomy if necessary. From the fifteenth day (day 15): rehabilitation to exercise after an exercise stress test with or without MVO

La dysfonction diastolique du ventricule gauche (LVDD), une forme d’insuffisance cardiaque, est une maladie qui affecte la compliance du myocarde. Contrairement à l’insuffisance cardiaque systolique, aucun traitement contre cette pathologie n’est approuvé à ce jour en clinique. L’absence d’un traitement efficace est liée à la complexité des mécanismes responsables du développement de la LVDD ainsi qu’au petit nombre de modèles animaux reflétant sa physio-pathologie. Dans notre laboratoire, nous avons démontré qu’un mimétique de l’apolipoprotéine A-I (apoA-I), composante majeure des lipoprotéines de haute densité (HDL), améliore la LVDD dans un modèle de sténose valvulaire aortique (SVA) chez le lapin. La SVA peut causer une LVDD. Le premier objectif de cette thèse fut de développer un modèle animal de LVDD sans SVA. Le deuxième objectif fut de tester les effets potentiels de l’apoA-I sur cette pathologie et d’élucider les mécanismes d’action impliqués dans ces effets. Pour ce faire, nous avons utilisé deux différents modèles expérimentaux chez le lapin. Le premier était basé sur l’exposition des lapins à une diète riche en cholestérol pendant une période moyenne de 16 semaines (sans excès de vitamine D2 afin de ne pas causer de développement de SVA). Le deuxième est un modèle chirurgical de constriction au niveau aortique (TAC) où les lapins développent la LVDD dans un délai de moins de 12 semaines suivant la chirurgie sans l’implication de la valve aortique. Nous avons par la suite traité ces lapins à l’aide d’un mimétique de l’apoA-I pour une durée de 4 semaines à raison de 3 injections de 25 mg/kg par semaine. Des sessions d’échocardiographies ont été réalisées afin d’évaluer le stade de la maladie à différents moments de l’étude. Les effets du traitement sur le plan moléculaire ont été évalués par des expériences de qPCR et d’immunohistochimie. Dans nos deux modèles de lapins, nous avons réussi à induire une LVDD sans la présence de SVA. À la fin de la période de traitement, notre médicament n’a pas amélioré significativement la LVDD chez les lapins. Seuls quelques effets positifs modestes du traitement au niveau de l’inflammation ont toutefois été remarqués. Ces résultats nous ont permis de déterminer que les effets positifs sur la LVDD des mimétiques de l’apoA-I que nous avons précédemment vus dans une étude antérieure ne sont pas directement liés à des bénéfices au niveau du myocarde mais qu’ils sont plutôt médiés par l’amélioration de la SVA., Left ventricular diastolic dysfunction (LVDD), a precursor form of heart failure, is a condition that affects compliance and relaxation of the myocardium. Unlike systolic heart failure, there is no clinically approved treatment yet for LVDD. Complexity of the pathways behind this disease as well as the small number of adequate animal models reflecting its physiopathology are the main causes of this lack of treatment. In our laboratory, we previously showed that mimetic of apolipoprotein A-I (apoA-I), a major component of high-density lipoproteins (HDL), improves LVDD in a rabbit model of aortic valve stenosis (AVS). AVS is one of the main risk factors which can cause LVDD. The first objective of this thesis is to develop a valid animal model of LVDD without AVS. The second objective is to test the potential effects of apoA-I on this pathology and to elucidate the mechanisms of action behind these effects. To do so, we used two different models of rabbits. The first, was based on the exposure of rabbits to a high-cholesterol diet for an average period of 16 weeks (without excess of vitamin D2 to prevent development of AVS). The second, is a surgical model of transaortic constriction (TAC). With this model, rabbits develop LVDD within 12 weeks after surgery, without involvement of AVS. Once LVDD was established, rabbits were treated with 3 injections of 25 mg/kg of apoA-I mimetic peptide weekly for 4 consecutive weeks. Echocardiography sessions were performed throughout the study to assess the stage of the disease at different time points. Molecular effects of the treatment were evaluated by qPCR and by immunohistochemistry experiments. In our two rabbit models, LVDD was established without the presence of AVS. At the end of the treatment period, our drug did not significantly improve diastolic dysfunction in rabbits. Only a few positive effects of treatment involved in the anti-inflammatory pathway have been noticed. In conclusion, these results allowed us to confirm that the positive effects of apoA-I mimetic peptide that we have previously reported on LVDD in another study were mediated by the improvement of AVS but not by a direct effect on the myocardium.

The performance and indications of transvalvular aortic valve implantation or TAVI has considerably expanded and is now the first therapeutic line option in the management of severe aortic stenosis. The targeted population shares both high risk of ischemic complications, particularly stroke or subclinical leaflet thrombosis of the bioprothesis, as well as hemorrhagic complications, strongly correlated to death. Based on previous experience with intracoronary stents, a dual antiplatelet therapy has been recommended by experts' consensus. This paradigm is now challenged by the observed increased risk of hemorrhagic complications without a reduction of ischemic events. Moreover, the role of non-vitamin K oral anticoagulant in patients undergoing TAVI remains to be determined. Several large ongoing randomized controlled trials will likely change our practice within the next coming year.

Since the first human implantation of a percutaneous aortic valve in 2002, tavi prosthesis didn't stop to improve their results. These improvements allowed to decrease dramatically tavi's complications and to extend the technic to patients with mid indeed low surgery risk. So tavi became the first treatment of aortic stenosis in France since a few years.

After a first procedure carried out in 2002 by Pr Cribier's, Transcatheter Aortic Valve Replacement or TAVR revolutionized the management of aortic stenosis with a constant increase in the number of procedures performed worldwide. Experience of operators and teams and evolution of the technique has been accompanied by a drastic reduction in complications in patients at lower surgical risk. In parallel, the procedure was considerably simplified, carried out more and more under local anesthesia, with percutaneous femoral approach, secondary radial approach, prosthesis implantation without predilatation, rapid pacing on left ventricle wire and early discharge. Thus, the "simplified" TAVR adopted in most centers nowadays is a real revolution of the technique. However, simplified TAVR must be accompanied upstream by a rigorous selection of patients who can benefit from a minimalist procedure in order to guarantee its safety.

Transcatheter aortic valve (TAVI) is the treatment of choice in patients with severe symptomatic aortic stenosis at high surgical risk. Recent data have also shown favorable results in patients considered to have an intermediate operative risk, which broadens the application of this new technology. Despite its success, the TAVI procedure has been associated with life-threatening complications. Advances in preoperative screening and patient selection have reduced the incidence of these complications. When these complications occur, early recognition and rapid management are essential. The purpose of this review is to describe non-rhythmic mechanical complications attributable to TAVI procedures with their predictive factors, how to prevent and manage them.

Transcatheter aortic valve implantation (TAVI) is currently becoming the treatment of choice for patients with calcific aortic stenosis. Despite several technical improvements, the incidence of conduction disturbances has not diminished and remains TAVI's major complication. These disturbances include the occurrence of left bundle branch block and/or high-grade atrioventricular block often requiring pacemaker implantation. The proximity of the aortic valve to the conduction system (conduction pathways) accounts for the occurrence of these complications. Several factors have been identified as carrying a high risk of conduction disturbances like the presence of pre-existing right bundle branch block, the type of valve implanted, the volume of aortic and mitral calcifications, the size of the annulus and the depth of valve implantation. Left bundle branch block is the most frequent post TAVI conduction disturbance. Whereas the therapeutic strategy for persistent complete atrioventricular block is simple, it becomes complex in the presence of fluctuating changes in PR interval and left bundle branch block duration. The QRS width threshold value (150-160 ms) indicative of the need for pacemaker implantation is still being debated. Although there are currently no recommendations regarding the management of these conduction disturbances, the extension of TAVI indications to patient at low surgical risk calls for a standardization of our practice. However, a decision algorithm was recently proposed by a group of experts composed of interventional cardiologists, electrophysiologists and cardiac surgeons. There are still uncertainties about the appropriate timing of pacemaker implantation and the management of new onset left bundle branch block.

Transcatheter aortic valve implantation (TAVI) has become the major approach to manage the severe aortic stenosis in inoperable patients that frequently present a coronary artery disease. To date, the available data related to the impact of these coronary lesions on survival is conflicting. When indicated, coronary revascularization could be beneficial for proximal lesions when performed before or during TAVI. The per-procedure coronary artery occlusion is rare, but with a bad prognosis. The coronary occlusion is more frequent with short distance of the coronary implantation and the small aortic sinuses, mostly occurring in the left main coronary. The scan analysis to identify high-risk cases is therefore important before the procedure in order to anticipate and prevent complications by specific techniques. Recently, late occlusion cases have been described and linked to thrombus or fibrosis mechanisms. The rate of success of percutaneous coronary intervention (PCI) after TAVI approach is weak, because of the difficulties of selective catheterization due to the stent of prosthesis. The different techniques of PCI have been outlined according to the type of the prosthesis.

The number of TAVI procedures is rapidly increasing owing to the extension of indications. Procedural and long-term success warrant appropriate patient selection and rigorous preparation of the procedure during the pre-TAVI work-up. The aims of this work-up are several: validation of the indication, feasibility and safety of the procedure, selection of the prosthesis and of the route, anticipation of technical challenges. The CT-scan is the cornerstone of this assessment allowing for valve and vascular access appraisal. The geriatric evaluation remains important in the elderly, frail, high-risk patients. The assessment of cardiac and extracardiac comorbidities is systematic and may be incorporated into dedicated risk scores to improve the prediction of post-TAVI outcomes; this should be the basis of the decision-making process by the Heart Team.

The population of elderly patients comprises a high percentage of women. This population is more vulnerable due to the presence of numerous comorbidities and is, therefore, particularly exposed to the risk of aortic valve degeneration, resulting in aortic valve stenosis whose symptoms are predictors of poor short-term outcomes. In the presence of symptomatic aortic stenosis, the recommended therapeutic option in this vulnerable population is the implementation of transcatheter aortic valve implantation, preferably via the femoral route. The outcomes of this procedure are better in women than in men despite a more frequent occurrence of vascular, bleeding and cerebral complications. Several hypotheses have been reported in the literature regarding the reasons for such differences. Among other reasons, it is likely that in female patients, the myocardium adjusts better to the occurrence of aortic stenosis and that recovery after valve treatment is also more optimal. Another explanation is the higher frequency of coronary artery disease in this older population. This has a considerable impact on the outcome even when coronary lesions are treated prior to valve implantation. There is still room for improvement and progress can be achieved by further reducing the size of the equipment used in order to decrease the diameter of the vascular access, and by continuing to simplify TAVI procedures. Less invasive techniques should result in decreased complication rates. In addition, dedicated studies should allow us to further improve our practice in this growing population of vulnerable patients.

Since the first transcatheter aortic valve implantation (TAVI) in 2002, the paradigm for the treatment of severe aortic stenosis has changed. In the recent past, medical therapy with or without balloon aortic valvuloplasty was the only option for inoperable patients but now, TAVI has become the treatment of choice for these patients and the preferred alternative for high-risk operable patients. Surgical aortic valve replacement (SAVR) currently remains the gold standard for patients at low operative risk. As randomized trials have demonstrated comparable (or better results with TAVI) between TAVI and SAVR in the high-risk population, there is now a clear trend towards performing TAVI even in intermediate-risk. Nevertheless, there are still questions regarding TAVI involving paravalvular leak, stroke, pacemaker requirements, and durability, which remain to be more definitively answered before TAVI can routinely be performed in lower risk and younger population. Improvements in patient selection, multimodal imaging, and third generation devices have significantly decreased the incidence of TAVI complications. A role for post-procedure antithrombotic or anticoagulant management remains unanswered. Waiting for current studies to provide us with clear answers to these questions, it is the Heart Team's task to determine the optimal treatment for each patient based on risk scores, frailty metrics, comorbidities, patient's preference, and potential for improvement in quality of life.Depuis la première implantation chez l’homme d’une prothèse aortique via un cathéter percutané en 2002 (TAVI, «Transcatheter Aortic Valve Implantation»), nous avons assisté à un changement de paradigme en ce qui concerne le traitement des sténoses aortiques. Dans un passé récent, le traitement médical, avec ou sans valvuloplastie au ballonnet, était la seule option thérapeutique pour les patients inopérables, mais, actuellement, le TAVI s’est imposé comme le traitement de choix pour ces patients et ceux à haut risque chirurgical. Le remplacement valvulaire aortique chirurgical classique reste le traitement de choix pour les patients symptomatiques à faible risque opératoire. Des études randomisées ont démontré des résultats équivalents, voire supérieurs, du TAVI comparé à la chirurgie chez les patients à haut risque et il y a actuellement de solides arguments en faveur de l’approche transcathéter chez les patients à risque intermédiaire. Cependant, avant d’élargir les indications du TAVI aux patients plus jeunes ou à faible risque, certaines questions relatives aux points faibles de cette technique telles les insuffisances paravalvulaires, les complications neurologiques, les implantations de pacemakers et la longévité des prothèses sont en attente de réponses plus précises. L’amélioration de la sélection des patients, de l’imagerie multimodale, les troisièmes générations de prothèses ont permis de réduire considérablement l’incidence des complications liées au TAVI. Il reste encore à définir un protocole efficace de traitement antithrombotique ou anticoagulant en post-procédure. En attendant que les études en cours nous apportent des réponses claires à ces questions, c’est le rôle du «Heart Team» de déterminer, au travers d’une discussion collégiale entre experts de différentes disciplines, le traitement de choix pour chaque patient, en tenant compte des scores de risque, de l’évaluation des fonctions cognitives, des comorbidités, des préférences du patient et de l’impact du traitement sur la qualité de vie.

The elderly benefit from the advances of the interventional cardiology, especially for coronary artery disease and aortic valve stenosis. The prevalence of comorbidities is high in old population, but the benefit-risk balance remains often positive. Chronic kidney disease is frequent and amplifies the risks of contrast-induced nephropathy and acute kidney injury with an impact on clinical course and outcomes, and additional costs. Preventive strategies recognized as efficient to limit renal adverse events must be applied. Future approach may involve research in vulnerable old patients undergoing cardiac interventions.

TAVI is currently recommended for severe symptomatic aortic stenosis in patients at prohibitive, high or intermediate surgical risk as estimated by surgical risk scores (STS score and EuroSCORE II). Comorbidity, technical feasibility of TAVI and concurrent pathology with need for complementary surgical correction are conditions to be considered to choose between open surgery and TAVI. The decision is often made by the "Heart Team". The transfemoral access must be favored. Conduction disturbance, stroke, bioprosthesis thrombosis and durability are the main setbacks of TAVI. Double antiplatelet therapy with aspirin and clopidogrel during 3 to 6 months is currently recommended after TAVI, followed by long-term aspirin single therapy.

This work is part of computer-assisted endovascular navigation. The aim of this thesis is to study and to propose new solutions for the localization and the tracking of moving endovascular devices within anatomical structures, which can be considered fixed or moving. The objective is to facilitate the endovascular intervention, by maximizing the accuracy and reliability of procedures, while minimizing the use of X-rays and contrast agents. The works concern : - The study of registration approaches to align pre-operative 3D data describing the anatomical structures and intra-operative 3D electromagnetic data (positions of a catheter equipped with a magnetic sensor at its tip). In the context of the treatment of abdominal aortic aneurysms (AAA), two fiducial-free registration methods that exploit only the endovascular trajectories (with total or partial correspondence hypothesis) have been proposed. The tests were performed on an AAA phantom. Although the localization accuracy of electromagnetic systems is still limited, these could be used to assist endovascular navigation (e.g., catheterization of collateral arteries). - The elaboration of a method to track calcifications and markers in fluoroscopic sequences, in the context of transcatheter aortic valve implantation (TAVI) procedures. We proposed a method of tracking by adaptive appearance model (TMAA). The approach was evaluated on 13 fluoroscopic sequences as part of TAVI native valve procedures and 5 fluoroscopic sequences as part of TAVI valve-in-valve procedures. The average localization error was less than 1 mm and the average processing time was 32.23 ms/frame. The evaluation of this method and its application on patient data has made it possible to show the precision and the compatibility of the tracking with a clinical use.; Ces travaux s’inscrivent dans le cadre de la navigation endovasculaire assistée par ordinateur. L’objectif principal est d’étudier et de proposer de nouvelles solutions pour la localisation et le suivi des dispositifs endovasculaires en mouvement par rapport aux structures anatomiques, considérées comme immobiles ou mobiles. Il s’agit à terme de faciliter le geste interventionnel, en maximisant la précision et la fiabilité des procédures, tout en minimisant le recours aux rayons X et au produit de contraste. Les travaux et résultats obtenus concernent : - L’étude d’approches de recalage permettant de fusionner des données 3D pré-opératoires décrivant les structures anatomiques et des données intra-opératoires de localisation 3D électromagnétique (positions d’un cathéter équipé d’un capteur magnétique en son extrémité). Dans le contexte du traitement des anévrismes aortiques abdominaux, deux méthodes de recalage ne nécessitant pas de marqueur externe et exploitant uniquement les trajectoires endovasculaires (avec hypothèse de correspondance totale ou partielle) ont été proposées. Les tests ont été réalisés sur fantôme physique. Bien que la précision de localisation des systèmes électromagnétiques soit encore limitée, ceux-ci pourraient être utilisés pour aider la navigation endovasculaire, comme par exemple, lors du cathétérisme d’artères collatérales. - L’élaboration d’une méthode de tracking des calcifications et de repères dans les séquences d’images fluoroscopiques, dans le contexte des procédures d’implantation endovasculaire de valve aortique (TAVI). Nous avons proposé une méthode de tracking par modèle d’apparence adaptatif (TMAA). L'approche a été évaluée sur 13 séquences fluoroscopiques dans le cadre des procédures TAVI valve native et 5 séquences fluoroscopiques dans le cadre des procédures TAVI valve-in-valve. Elle fournit une erreur de localisation moyenne inférieure à 1 mm et un temps de traitement de 32,23 ms/trame. L’évaluation de cette méthode et son application sur données patients ont permis de montrer la précision et la compatibilité du tracking avec une utilisation clinique.

Nearly 20 years have passed from the concept to clinical development of percutaneous aortic valve replacement, starting from an idea considered "stupid" of Professor Alain Cribier in Rouen. After a first phase of compassionate implantation, large randomized trials PARTNER and COREVALVE US have allowed TAVI to impose itself in the European and American recommendations in patients inoperable or considered with high surgical risk. Next European recommendations on the management of valvular heart diseases expected in 2017 should take into account the positive results observed in intermediate risk patients in the PARTNER 2 and SURTAVI studies, recently adopted in the US recommendations. Randomized trials in "all coming" patients are already on their way, and the future of TAVI is to be the reference treatment for a vast majority of patients with aortic stenosis.

Aortic valve stenosis (AS) is the most commonly operated valvular heart disease in developed countries. Aortic valve replacement is the sole effective treatment of symptomatic patients. PARTNER-1 (Placement of AoRtic TraNscathetER Valves) has recently proved the efficacy of percutaneous aortic valve replacement (TAVI : Transcatheter Aortic Valve Implantation) in patients at high surgical risk, or inoperable. In the present article, we report and discuss the results of the PARTNER-2 study in intermediate risk patients. Data from PARTNER-2 confirmed those of PARTNER-1 with a similar rate of combined events (death or disabling stroke) in the TAVI and surgical groups. At 2 years, the Kaplan-Meier event rates were 19.3% in the TAVI group and 21.1% in the surgery group, with a hazard ratio in the TAVI group of 0.89. The non inferiority analysis was validated with a p inferior to 0.001. In the transfemoral-access cohort, TAVI resulted in a lower rate of death or disabling stroke than surgery (p = 0.05), whereas, in the transthoracic access cohort, outcomes were similar in the two groups. Finally, TAVI was associated with lower rates of new onset atrial fibrillation, acute renal failure, and severe bleeding, whereas surgery resulted in fewer major vascular complications and less paravalvular aortic regurgitation.La sténose aortique est la valvulopathie la plus fréquemment opérée dans les pays industrialisés. Le remplacement valvulaire aortique est le seul traitement efficace dans les formes sévères symptomatiques. L’étude PARTNER-1 (Placement of AoRtic TraNscathetER Valves/Mise en place de valves aortiques transcathéters) a récemment prouvé l’efficacité du remplacement valvulaire aortique par voie percutanée (TAVI: Transcatheter Aortic Valve Implantation) chez les patients à haut risque chirurgical ou inopérables. Dans cet article, nous rapportons et discutons les résultats de l’étude PARTNER-2 réalisée chez les patients à risque intermédiaire. PARTNER-2 confirme les données observées dans PARTNER-1, avec un critère d’évaluation principal [taux d’événements combinés, décès ou accident vasculaire cérébral (AVC) invalidant] similaire dans les deux groupes (TAVI versus chirurgie). A deux ans, l’incidence de ce critère primaire était de 19,3 % dans le groupe TAVI versus 21,1 % dans le groupe chirurgie, soit un risque relatif de 0,89 dans le groupe TAVI. L’analyse de non-infériorité était validée (p inf�rieur a 0,001). Le TAVI par voie transfémorale était associé à un plus faible taux de décès ou d’AVC invalidant que la chirurgie (p = 0,05), tandis que, dans l’approche transthoracique, le pronostic des patients était similaire dans les deux groupes. Finalement, le TAVI était associé à une incidence moindre de fibrillation auriculaire de novo, d’insuffisance rénale aiguë, et d’hémorragies sévères, tandis que l’avantage de la chirurgie se traduisait par moins de fuites paravalvulaires et de complications vasculaires.

Polyvalvular disease is not a rare condition, the lack of specific data for each situation does not allow perfoming standardized management and guidelines. We want to present by this review available data on the management of polyvalvular disease, taking into account different possible associations between the valve lesions.

Demographic data point to a substantial proportion of women in the population of elderly patients with an increasing prevalence of aortic stenosis. Implantation of an aortic bioprosthesis via an endovascular approach known as Transcatheter aortic valve implantation (TAVI) in patients presenting with a symptomatic tight aortic stenosis (severe aortic stenosis) (AS) is an alternative therapeutic option to surgical aortic valve replacement in patients at high surgical risk or ineligible for surgery. The literature has shown that this technique seems to be particularly beneficial in female patients. In the Partner A trial, the 1-year mortality rate was significantly lower in women compared to their male counterparts. Other data revealed that although women have a higher risk of experiencing periprocedural complications (vascular events, bleeding and stroke), their outcome is good and often better than that of men. These results are continuously improving thanks to the enhancement of techniques and devices. In view of the published reports reflecting the increasing experience of the teams, it clearly appears that the simplification of TAVI procedures has resulted in improved outcomes. We report here the case of a patient treated by means of a "minimalist" approach to TAVI allowing a reduction of the risks inherent in the procedure. This simplified strategy relies on an optimal use of CT scan findings prior to TAVI. The procedure is carried out under local anesthesia and the main access site is sutured percutaneously (Proglides). The radial artery is used as a secondary access site. Contrast medium is diluted and stimulation is administered via the intraventricular guidewire. Direct stenting is performed when deemed feasible on the basis of CT scan results. Simplified procedures such as these contribute to the improvement of TAVI outcomes. However, further studies focusing on female patients are warranted in order to corroborate these findings.

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.

A 54-year-old woman was hospitalized for an acute pulmonary oedema revealing a severe aortic stenosis (AS) associated with an aortic aneurysm and a left ventricular hypertrophy (LVH). The coronary angiography found an equivocal left main lesion. Fractional flow reserve (FFR) showed hemodynamic significance (FFR=0.78) and optical coherence tomography confirmed this result with a minimal lumen area of 4.9mm

Balloon aortic valvuloplasty is a relatively simple procedure with a low rate of complications despite patients' frailty. Urgent balloon aortic valvuloplasty is especially useful in patients with temporary contra-indication to TAVI or in case of difficult clinical scenario. It allows for a functional improvement for up to 6 months. This period should be used to bridge the patient to TAVI or surgical aortic valve replacement, stand-alone aortic valvuloplasty being without mid-term survival benefit.

Aortic stenosis (AS) is the most common valvular heart disease in adults. The most frequent aetiology is now degenerative AS. There is general agreement that, in the absence of serious co-morbidity, surgery must be recommended for patients with symptomatic disease. The management of asymptomatic patients with severe aortic disease remains controversial for several reasons: sudden death in asymptomatic patients has been reported with an incidence1 % per year. In addition, operative mortality is significantly higher in symptomatic, when compared with asymptomatic, patients. Patients should be carefully educated about the importance of follow-up and reporting symptoms as soon as they develop. Echocardiography confirms the diagnosis and the severity of aortic stenosis. Exercise testing may be helpful when the patient is asymptomatic. If the patient develops symptoms during test, he should be referred for surgery. The management of patients with AS in everyday practice is based on the guidelines developed by ESC in October 2012.

Although surgical aortic valve replacement has been the standard of care for patient with severe aortic stenosis, transcatheter aortic valve implantation (TAVI) is now a fair standard of care for patients not eligible or high risk for surgical treatment. The decision of therapeutic choice between TAVI and surgery considers surgical risk (estimated by the Euro-SCORE and STS-PROM) as well as many parameters that go beyond the assessment of the valvular disease's severity by echocardiography: a multidisciplinary assessment in "Heart Team" is needed to assess each case in all its complexity.

Transcatheter aortic valve implantation (TAVI) is a treatment for high-risk patients with symptomatic severe aortic stenosis. The aim of the study is to assess results of comprehensive geriatric assessment before TAVI and geriatrician advices about TAVI procedure feasibility. We report one-year outcomes after TAVI procedure.All patients who underwent comprehensive geriatric assessment in geriatric day hospital before TAVI were prospectively included in Grenoble. We report characteristics of the patients, geriatrician advices about TAVI procedure feasibility and risks, and one year follow-up.Twenty-one frail elderly patients underwent geriatric assessment. The mean age was 85.4; demographics included cognitive impairment (76%), renal dysfunction (81%), NYHA functional class III or IV (48%). Eighteen patients were suitable for TAVI according to geriatric assessment, 8 underwent TAVI. None of the 3 patients who were not candidate for TAVI according to geriatricians were implanted. Cardiologists followed geriatrician advices for 56% of cases. Intensive care unit and cardiology stay were prolonged at 3.5 and 7.9days, respectively. Six out of the 8 patients stayed in rehabilitation unit after TAVI. None of the implanted patients died at one-year follow up, despite of the common periprocedural complications: acute kidney injury, ischemic stroke, delirium, pacemaker, hemorrhage.Cardiologists follow geriatrician advices about TAVI feasibility in frail elderly patients. Comprehensive geriatric assessment also helps preventing complications and providing quick assessment of occurring periprocedural and postprocedural complications. Optimal management of frail elderly patients undergoing TAVI is a multidisciplinary task involving cardiologists, anaesthetists and geriatricians.

Transcatheter aortic valve implantation (TAVI) is indicated in patients with severe symptomatic aortic stenosis who are not suitable for surgery or should be considered when there is a high surgical risk as assessed by a heart team. There is a decrease in mean logistic EuroSCORE since January 2010, which translates a gradual evolution in patients' selection. Expertise of geriatricians to further assess frailty is a key step in the risk stratification process of this elderly population (mean age: 83.4±7.3 years). Femoral access is used in 80% of cases with a procedural success rate higher than 95%. In-hospital mortality rate is 5.9%. The main complications of the procedure are aortic annulus rupture (0.9% in FRANCE TAVI), tamponade (2.3%), stroke (2.2%), severe paravalvular leak (1.3%) and permanent pacemaker implantation (15%). The awaited results of PARTNER II and SURTAVI may lead to expand the indications to lower-risk patients if it is shown that TAVI is non-inferior to surgery in this population which has been suggested by the recent randomized NOTION Trial while the CoreValve Pivotal Trial even points in the direction of a possible superiority of the percutaneous technique over surgery.

Introduction: L’utilisation clinique de biomarqueurs pour prédire la progression de la sténose valvulaire aortique (SVA) n’est pas encore validée à ce jour. Nous voulons évaluer des prédicteurs de la progression de la SVA d’étiologie dégénérative sur la valve aortique tricuspide. Méthodes: Nous avons identifié 126 cas avec SVA et ≥ 2 échocardiogrammes post-recrutement et 126 témoins appariés recrutés par la Biobanque de l’Institut de Cardiologie de Montréal. Nous avons collecté des données cliniques, échocardiographiques et génétiques de base et nous avons mesuré des biomarqueurs plasmatiques. L’évolution de la SVA a été établie par l’analyse des échocardiogrammes sériés et définie comme la variation moyenne par an des paramètres suivants: vitesse transvalvulaire aortique maximale, gradient transvalvulaire aortique moyen (GTAM), aire valvulaire aortique et aire valvulaire aortique indexée. Nous avons évalué l’association des données cliniques/échocardiographiques/génétiques (polymorphisme LPA rs10455872) avec la progression de la SVA et des biomarqueurs plasmatiques avec la présence et la progression de la SVA. Résultats: La durée moyenne de suivi a été de 2,4 ans. Selon des analyses multivariées concernant les données cliniques/échocardiographiques/LPA rs10455872, une fréquence cardiaque plus élevée (pour les patients plus agés et les hommes), le diabète (pour les hommes), et un plus grand GTAM au premier échocardiogramme sont associés à une évolution plus rapide de la SVA. La présence de régurgitation aortique au premier échocardiogramme est associée à une évolution plus lente de la SVA. L’analyse des biomarqueurs plasmatiques versus la présence et la progression de la SVA est en cours. Conclusion: Nos résultats indiquent que une fréquence cardiaque plus élevée, le diabète, et un plus grand GTAM au premier échocardiogramme sont associés avec une progression plus rapide de la SVA. Les résultats de cette étude pourraient contribuer à une approche plus personnalisée du suivi et du traitement de la SVA., Introduction: The clinical use of biomarkers to predict the progression of aortic valve stenosis (AVS) is not yet validated. We want to evaluate potential predictors of the progression of degenerative AVS on tricuspid valve. Methods: We identified 126 cases with AVS and ≥ 2 echocardiograms post-recruitment and 126 paired controls recruited by the Montreal Heart Institute’s Biobank. We collected clinical, echocardiographic and genetic base data and measured plasma biomarkers. The AVS evolution was established by the analysis of the serial echocardiograms and defined as the mean variation per year of the following parameters: maximal aortic transvalvular velocity, mean aortic transvalvular gradient (MATG), aortic valve area and indexed aortic valve area. We evaluated the association of clinical, echocardiographic and genetic (LPA rs10455872 polymorphism) data with the AVS progression and plasma biomarkers with the AVS presence and progression. Results: The mean follow-up was 2.4 years. According to multivariate analysis concerning the clinical/echocardiographic/ LPA rs10455872 data, a higher heart rate (for older patients and males), diabetes mellitus (for males) and a greater MATG in the first echocardiogram are associated to a faster AVS evolution. The presence of aortic regurgitation in the first echocardiogram is associated to a slower AVS evolution. The analysis of plasma biomarkers versus the AVS presence and progression is ongoing. Conclusion: Our results indicate that a higher heart rate, diabetes mellitus, and a greater MATG are associated with faster AVS progression. The results of this study should contribute to a more personalized approach of the AVS follow-up and treatment.

As the French population is aging, a growing number of elderly patients with symptomatic severe aortic stenosis are going to require therapeutic management. Approximately 30 to 40 % of these patients do not undergo surgical treatment and a high proportion is considered to be at high risk for surgery. The transluminal aortic valve implantation technique has been increasingly used over the past few years, thus providing a solution to a major therapeutic issue in our industrialized countries. Thanks to major randomized studies such as the PARTNER US trial, this treatment has been approved for high-risk patients. Expertise and new devices are now opening the way to intermediate risk population.

Aortic stenosis is the most common valvular heart disease in Europe and North America and it is a real public health problem. Its prevalence increases with population aging. Symptomatic patients require surgery (class I, level of evidence B). In asymptomatic patients, a stress test with or without imaging is recommended to unmask the false asymptomatic patients and refine risk stratification of occurrence of major events. This support remains difficult and makes the optimal timing for surgery controversial in the absence of prospective data on the determinants of aortic stenosis progression, multicenter studies on risk stratification or randomized studies on patient management. The complexity of care arises from the balance between the spontaneous disease risk (risk of sudden death and irreversible left ventricular dysfunction) and the risk of surgery and prosthetic complications. It is therefore crucial to identify subgroups of patients at risk of pejorative progression in whom prophylactic surgery may be considered. This article focuses on evaluating during exercise asymptomatic patients with severe aortic stenosis and preserved left ventricular ejection fraction. We will explain how to perform the test, determine which echocardiographic measurements should be obtained, focusing on the diagnostic and prognostic value of these measurements and discuss indications for surgery according to new practice guidelines.

Percutaneous aortic valve replacement (TAVI) is one of the most innovative procedure in interventional cardiology. The Direct Flow Medical transcatheter aortic valve (DFM) is a new nonmetallic valve which allows perfect repositioning and valve retrieval prior to the final deployment. This study is a prospective non-randomized evaluation of the DFM system in the Luxembourg registry. The study focused on 15 patients who received between March 2013 and October 2013 a percutaneous aortic valve replacement by DFM prosthesis. All clinical and echocardiographic data have been collected prospectively. Fifteen inoperable patients with severe aortic stenosis were evaluated. The average age of our population was 83 +/- 4.16 years, mean STS score was 16%. 46% of patients were in NYHA class III and 33.3% in NYHA class IV. Mean ejection fraction was 59% +/- 12.7, the average mean gradient was 52.86 +/- 18.5 mm Hg and mean aortic orifie was 0.63 +/- 0.15 cm2. Procedural success rate was 100%. The mean trans- valvular gradient decreased from 52.86 +/- 18.5 mm Hg to 12 +/- 4.2 mm Hg (p0.001). The average hospital stay was 14 +/- 7.6 days. The non-fatal major event rate at one month was 33.3%. The mortality rate at one month was limited to 6.6%. These results allow us to confirm the efficacy and safety of the DFM valve.

The coronary microcirculatory impairment is a key feature of the pathophysiology of aortic stenosis (AS), the most operated valvular disease over the world. Several studies showed this coronary microcirculatory impairment in AS, using different tools and protocols, in various patient population of AS. This article will review the impairment of the coronary microcirculation in AS underlining its multifactorial origin, its functional part related to the hemodynamic consequences of AS, its complex relationship with left ventricular hypertrophy, and its potential diagnostic and prognostic value.

There is a significant risk of cardiovascular morbidity and mortality in patients with severe aortic stenosis (valve area1cm(2) or 0.6cm(2)/m(2) body surface area, and maximum jet velocity ≥4m/sec, and mean aortic pressure gradient ≥40mmHg) undergoing non-cardiac surgery, especially in patients with symptoms (dyspnoea, angina, syncope, or heart failure). Before any surgery, clinical assessment should search for signs of aortic stenosis which justifies echocardiographic examination, particularly in the elderly. A systematic rest echocardiography with searching aortic stenosis should be considered in patients undergoing high risk surgery. The key points of pre-operative cardiac risk assessment are: assessment of the severity of aortic stenosis, measurement of the functional capacity, evaluation of the left ventricular systolic function, search of associated coronary artery disease, estimate of the surgical risk of cardiac events, and achievement of risk indices. In symptomatic patients with severe aortic stenosis, only urgent non-cardiac surgery should be performed under careful haemodynamic monitoring. Aortic valve replacement should be considered before elective non-cardiac surgery. In asymptomatic patients with severe aortic stenosis, aortic valve replacement should be considered before non-cardiac high risk surgery. Non-cardiac surgery at low/intermediate risk can be performed provided an adapted anaesthetic technique.

Aortic stenosis mostly occurs among old-old patients. Once symptoms appear, prognosis is guarded, with 2-year mortality as high as 50%. Transcatheter Aortic Valve Implantation (TAVI) is a new therapeutic option in patients at very high surgical risk, who are mostly older persons. However, TAVI is associated with some complications, and patient selection remains a challenge. Comprehensive geriatric assessment (CGA) identifies patients with medical and functional problems likely to affect the TAVI post-operative course. Collaboration between cardiologists and geriatricians will likely become a standard approach to enhance the assessment of these frail patients and identify those most likely to benefit from TAVI.