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ObjectivesThe TRI-SCORE reliably predicts in-hospital mortality after isolated tricuspid valve surgery (ITVS) on native valve but has not been tested in the setting of redo interventions. We aimed to evaluate the predictive value of the TRI-SCORE for in-hospital mortality in patients with redo ITVS and to compare its accuracy with conventional surgical risk scores.MethodsUsing a mandatory administrative database, we identified all consecutive adult patients who underwent a redo ITVS at 12 French tertiary centres between 2007 and 2017. Baseline characteristics and outcomes were collected from chart review and surgical scores were calculated.ResultsWe identified 70 patients who underwent a redo ITVS (54±15 years, 63% female). Prior intervention was a tricuspid valve repair in 51% and a replacement in 49%, and was combined with another surgery in 41%. A tricuspid valve replacement was performed in all patients for the redo surgery. Overall, in-hospital mortality and major postoperative complication rates were 10% and 34%, respectively. The TRI-SCORE was the only surgical risk score associated with in-hospital mortality (p=0.005). The area under the receiver operating characteristic curve for the TRI-SCORE was 0.83, much higher than for the logistic EuroSCORE (0.58) or EuroSCORE II (0.61). The TRI-SCORE was also associated with major postoperative complication rates and survival free of readmissions for heart failure.ConclusionRedo ITVS was rarely performed and was associated with an overall high in-hospital mortality and morbidity, but hiding important individual disparities. The TRI-SCORE accurately predicted in-hospital mortality after redo ITVS and may guide clinical decision-making process (www.tri-score.com).

Objectives The authors explored the development and validation of machine-learning models for augmenting the echocardiographic grading of aortic stenosis (AS) severity. Background In AS, symptoms and adverse events develop secondarily to valvular obstruction and left ventricular decompensation. The current echocardiographic grading of AS severity focuses on the valve and is limited by diagnostic uncertainty. Methods Using echocardiography (ECHO) measurements (ECHO cohort, n = 1,052), we performed patient similarity analysis to derive high-severity and low-severity phenogroups of AS. We subsequently developed a supervised machine-learning classifier and validated its performance with independent markers of disease severity obtained using computed tomography (CT) (CT cohort, n = 752) and cardiovascular magnetic resonance (CMR) imaging (CMR cohort, n = 160). The classifier’s prognostic value was further validated using clinical outcomes (aortic valve replacement [AVR] and death) observed in the ECHO and CMR cohorts. Results In 1,964 patients from the 3 multi-institutional cohorts, 1,346 (68%) subjects had either nonsevere or discordant AS severity. Machine learning identified 1,117 (57%) patients as having high-severity and 847 (43%) as having low-severity AS. High-severity patients in CT and CMR cohorts had higher valve calcium scores and left ventricular mass and fibrosis, respectively than the low-severity group. In the ECHO cohort, progression to AVR and progression to death in patients who did not receive AVR was faster in the high-severity group. Compared with the conventional classification of disease severity, machine-learning–based severity classification improved discrimination (integrated discrimination improvement: 0.07; 95% confidence interval: 0.02 to 0.12) and reclassification (net reclassification improvement: 0.17; 95% confidence interval: 0.11 to 0.23) for the outcome of AVR at 5 years. For both ECHO and CMR cohorts, we observed prognostic value of the machine-learning classifications for subgroups with asymptomatic, nonsevere or discordant AS. Conclusions Machine learning can integrate ECHO measurements to augment the classification of disease severity in most patients with AS, with major potential to optimize the timing of AVR.

Tricuspid regurgitation is a frequent and serious condition but tricuspid valve (TV) surgery, that may be a valve replacement when a repair is not feasible, is rarely performed. Recent development of transcatheter TV interventions offers new options for those high-surgical risk patients, especially TV replacement for patients who are not eligible for transcatheter TV repair. In this review, we describe indications and outcome after surgical TV replacement, and devices available or in development for transcatheter TV replacement.

International audience; Background. - A better understanding of the mechanism of tricuspid regurgitation severity would help to improve the management of this disease. Aim. - We sought to characterize the determinants of isolated secondary tricuspid regurgitation severity in patients with preserved left ventricular ejection fraction. Methods. - This was a prospective observational multicentre study. Patients with severe tricuspid regurgitation were asked to participate in a registry that required a control echocardiogram after optimization of medical treatment and a follow-up. Patients had to have at least mild secondary tricuspid regurgitation when clinically stable, and were classified according to five grades of tricuspid regurgitation severity, based on effective regurgitant orifice area. Results. - One hundred patients with tricuspid regurgitation (12 mild, 31 moderate, 18 severe, 17 massive and 22 torrential) were enrolled. Right atrial indexed volume and tethering area were statistically associated with the degree of tricuspid regurgitation (P= 50 mm, the probability of having severe tricuspid regurgitation or a higher grade was > 70%. For an increase of 10 mL/m(2) in right atrial volume, the effective regurgitant orifice area increased by 4.2 mm(2), and for an increase of 0.1 cm(2) in the tethering area, the effective regurgitant orifice area increased by 2.35 mm(2). The degree of right ventricular dilation and changes in tricuspid morphology were significantly related to tricuspid regurgitation severity class (P

International audience; No abstract available

The optimal management of aortic surgical bioprosthesis presenting with severe symptomatic structural valve deterioration is currently a matter of debate. Over the past 20 years, the number of implanted bioprostheses worldwide has been rapidly increasing at the expense of mechanical prostheses. A large proportion of patients, however, will require intervention for bioprosthesis structural valve deterioration. Current options for older patients who often have severe comorbidities include either transcatheter valve-in-valve (TVIV) implantation or redo valve surgery. The emergence of TVIV implantation, which is perceived to be less invasive than redo valve surgery, offers an effective alternative to surgery for these patients with proven safety and efficacy in high-risk patient groups including elderly and frail patients. A potential caveat to this strategy is that results of long-term follow-up after TVIV implantation are limited. Redo surgery is sometimes preferable, especially for young patients with a smaller-sized aortic bioprosthesis. With the emergence of TVIV implantation and the long experience of redo valve surgery, we currently have 2 complementary treatment modalities, allowing a tailor-made and patient-orientated intervention. In the heart team, the decision-making should be based on several factors including type of bioprosthesis failure, age, comorbidities, operative risk, anatomical factors, anticipated risks and benefits of each alternative, patient's choice and local experience. The aim of this review is to provide a framework for individualized optimal treatment strategies in patients with failed aortic surgical bioprosthesis.

Background: Longitudinal strain has been proposed as a sensitive marker of left ventricular systolic dysfunction. However its prognostic value in patients with aortic stenosis (AS) remains debated....

Background— Computed tomography aortic valve calcium scoring (CT-AVC) holds promise for the assessment of patients with aortic stenosis (AS). We sought to establish the clinical utility of CT-AVC in an international multicenter cohort of patients. Methods and Results— Patients with AS who underwent ECG-gated CT-AVC within 3 months of echocardiography were entered into an international, multicenter, observational registry. Optimal CT-AVC thresholds for diagnosing severe AS were determined in patients with concordant echocardiographic assessments, before being used to arbitrate disease severity in those with discordant measurements. In patients with long-term follow-up, we assessed whether CT-AVC thresholds predicted aortic valve replacement and death. In 918 patients from 8 centers (age, 77±10 years; 60% men; peak velocity, 3.88±0.90 m/s), 708 (77%) patients had concordant echocardiographic assessments, in whom CT-AVC provided excellent discrimination for severe AS (C statistic: women 0.92, men 0.89). Our optimal sex-specific CT-AVC thresholds (women 1377 Agatston unit and men 2062 Agatston unit) were nearly identical to those previously reported (women 1274 Agatston unit and men 2065 Agatston unit). Clinical outcomes were available in 215 patients (follow-up 1029 [126–2251] days). Sex-specific CT-AVC thresholds independently predicted aortic valve replacement and death (hazard ratio, 3.90 [95% confidence interval, 2.19–6.78]; P P =0.010). Conclusions— Sex-specific CT-AVC thresholds accurately identify severe AS and provide powerful prognostic information. These findings support their integration into routine clinical practice. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifiers: NCT01358513, NCT02132026, NCT00338676, NCT00647088, NCT01679431.

Series evaluating the results of isolated tricuspid valve surgery (ITVS) are rare and often limited by small sample size, selection bias, and/or long period of enrollment. Based on a mandatory administrative national database, we collected all consecutive ITVS performed in France during a 2-year period (2013 and 2014), the type of intervention, clinical profile, and in-hospital mortality and complications. During the 2-year period, 241 patients underwent an ITVS in France (84 repairs and 157 replacements). In-hospital mortality was high (10%), and most patients experienced at least 1 complication (65%) with a 19% rate of major complications (death, need for dialysis, or need for mechanical support using extracorporeal membrane oxygenation). Consequently, hospital duration was remarkably long (26 ± 40 days). Congestive heart failure at presentation was associated with mortality and major complications rates (both p = 0.01). In conclusion, in a contemporary and consecutive series, ITVS was associated with a high mortality and morbidity predicted by clinical presentation at baseline. Our results suggest that patients are often referred too late and that an earlier intervention may improve immediate and possibly midterm outcomes. With the availability of transcatheter therapies in a near future, optimal timing of intervention in this population will be of utmost importance.

BACKGROUND Few data are available on the application of transoesophageal echocardiography (TOE) recommendations in daily practice. AIMS To evaluate TOE practice based on echocardiography societies' guidelines, and to determine complication rates and factors associated with patient feelings. METHODS Between April and June 2017, we prospectively included all consecutive patients referred to 14 French hospitals for a transoesophageal echocardiogram (TOE). A survey was taken just after the examination, which included questions about pre-procedural anxiety, and any pain, unpleasant feeling or breathing difficulties experienced during the examination. RESULTS Overall, 1718 TOEs were performed, mainly for stroke evaluation. A standardized operating procedure checklist was completed in half of the patients before the examination. TOE was unpleasant for 62.4% of patients, but was stopped for agitation or intolerance in 3.5 and 1.4% of cases, respectively. We observed one severe complication (pulmonary oedema). The mean TOE duration was short (9.2±4.6minutes), but was longer with residents than with more experienced physicians (11±4.7 vs. 8.8±4.7minutes for junior physicians [P=0.0027]; vs. 8.9±4.8minutes for senior physicians [P=0.0013]; and vs. 7.5±4.1minutes for associate professors/professors [P

The surgical management of mitral valve endocarditis is still argument of debate. We reviewed the current evidences regarding preoperative assessment, timing for surgery, operative strategy and antibiotic treatment and elaborated a systematic approach to endocarditis management based on clinical and anatomopathological variables known to affect postoperative outcomes. An algorithm to guide decision-making in mitral valve endocarditis, which includes etiology, clinical presentation, and anatomic extension of the infection at preoperative imaging, has been designed. Hemodynamic instability, extensive valvular lesions, elevated risk of embolization and inability to control the infection notwithstanding appropriate antibiotic treatment, are considered indications for urgency or emergency surgery. Type of operation to be performed should be dependent on the etiology (i.e., non-invasive or invasive organism), extent of the infective lesion, involvement of a native or a prosthetic valve, and patient age and comorbidities, including the presence of cardiac and/or extra-cardiac organ dysfunction. In case of single infected scallop, a reparative strategy should be preferred and coupled with vegetectomy or reconstruction of the perforated mitral segment with a pericardial patch. In cases that involve two or three scallops, left ventricular dysfunction, or renal or other extra-cardiac organ failure, valve repair is not recommended and valve replacement with either prosthetic or allogeneic tissues should be performed. Evidence of complex endocarditis with involvement of the mitral annulus or abscess of the mitro-aortic junction, requires extensive demolitive surgery and the use of homografts and synthetic material.

Objectives It has been suggested that myocardial systolic deformation parameters may be a more sensitive marker of left ventricular (LV) systolic dysfunction than LV ejection fraction (LVEF). However, its prognostic value in patients with aortic stenosis (AS) remains debated. Methods In an ongoing prospective cohort of asymptomatic patients with at least mild, pure, isolated AS, global longitudinal strain (GLS) was measured at baseline using 2D speckle tracking imaging, and AS related events (occur-rence of symptoms, congestive heart failure and sudden death) were prospectively collected. Results We prospectively enrolled 176 patients (mean age 72 years, 70% male). Mean aortic valve area was 1.25cm2 and mean gradient 28.8mmHg. Overall, 88 patients had mild AS, 50 patients moderate AS and 38 patients severe AS. During a mean follow up period of 2.2 years, 38 events occurred. GLS was not correlated to pic velocity, mean gradient or aortic valve area (AVA) (all p>0.05). In univariate analysis, neither in the whole cohort (p=0.75), nor in the subgroup of moderate/severe AS, GLS was predictive of future AS related events. Results were unchanged after adjustment for AS hemodynamic severity (p=0.66 and p=0.82, respectively). Conclusions Our data suggest that longitudinal strain assessed by 2D speckle tracking echocardiography, is not predictive of future symptomatic status in asymptomatic patients with AS and preserved LVEF. Thus, this index should not be recommended in daily practice, in order to select patients who should undergo an early aortic valve replacement.

BackgroundThe tricuspid annulus (TA) is a complex structure that has been rarely evaluated. Three-dimensional transesophageal echocardiography (3D-TEE) gives us the unique opportunity to evaluate TA shape and dimensions.Methods3D dynamic volumetric datas of the TA were acquired by TEE using a matrix array transducer (X7-2t, Philips) in 184 patients. Multiplanar reconstructions were performed offline using a dedicated software (QLab7, Philips). Long-axis (LA) diameter, short-axis (SA) diameter and the area of the TA at the time of its maximal opening were measured. The eccentricity index (EI) of the TA was defined as LA/SA and TA orientation as the angle between the interatrial septum axis (aortic valve on the top at 0°) and the LA in the surgical view.ResultsMorphology of TA was more often oval (EI=1.35±0.22) but shapes were significantly different among indivuals, from circular to oval (EI values from 1 to 2.15). TA dilatation occurred homogeneously in all the directions of the right ventricle free wall as attested by the very good correlation between the TA area and both LA (r=0.89, p

Whether a percutaneous mitral commissurotomy (PMC) should be attempted in patients with mitral stenosis (MS) and valvular calcification, especially located at the commissural level remained debated. We sought to evaluate the impact of the degree and location of mitral valve calcifications on PMC results.Over a 3-year period, we enrolled 464 consecutive patients who underwent a PMC at our institution. According to the location (within the body valve leaflets' or at the commissural level) and the degree of calcification, patients were divided into three groups: 261 patients were in Group 1 (no leaflets' or commissural calcification), 141 in Group 2 (leaflets' calcification with no significant commissural calcification), and 62 in Group 3 (at least one commissure significantly calcified). Final valve area (1.83 ± 0.26, 1.71 ± 0.25, and 1.60 ± 0.24 cm(2), P0.00001) and the rate of complete opening of at least one commissure (92, 94, and 84%, P = 0.05) were significantly different. However, the rate of post-PMC mitral regurgitation (MR) of grade ≥ 3 (10, 10, and 8%, P = 0.90) was not different among the groups and if the rate of good immediate result, defined as valve area ≥ 1.5 cm(2) with no MR2/4 was different among the three groups (88, 78, and 73%, P = 0.004), an overallprocedural success could be achieved in most patients with calcified commissures.In this large contemporary series of patients with MS, a procedural success was obtained less frequently in patients with calcified commissure but a successful PMC could still be safely achieved in a large proportion of patients. Our results support the use of PMC as a first-line treatment of patients with severe MS even in the presence of significant commissural calcifications with otherwise favourable clinical characteristics.

Background Tricuspid annuloplasty is recommended during left-heart valve surgery when tricuspid annulus (TA) is dilated, independently of the degree of tricuspid regurgitation, but the methodology to measure TA and thresholds are not clearly defined. We aimed to compare TA diameter (TAD) measurements performed using bi-dimensional transthoracic echocardiography (2D-TTE) in the 4 different views to three-dimensional measurements performed during transesophageal echocardiography (3D-TEE) and to define thresholds of TA enlargement for routine practice. Methods 2D-TTE measurement of the TAD was performed in parasternal long-axis view of the right ventricle inflow, parasternal short-axis, apical 4-chamber (A4C) and sub-costal views in 195 prospectively enrolled patients and 66 healthy volunteers. 3D dynamic volumetric datas of the TA were also acquired by TEE using a matrix array transducer (X7-2t, Philips) in the 195 patients. Multiplanar reconstructions were performed offline using dedicated software (QLab7, Philips) to measure the long-axis (LA) of the TA. Results In the 195 patients, TAD measurements were not different between the 4 TTE views (P=0.13), but A4C was the most feasible and the most reproducible method (Table). TAD measurement in A4C view by TTE (3.90±0.62cm) was well correlated (r=0.84, p Conclusion TAD measurement in A4C view by 2D-TTE was highly feasible, reproducible and accurately reflected TA size, even if it was systematically underestimating its maximal diameter. Based on measurements in healthy volunteers, we suggest to consider tricuspid annuloplasty during left-heart valve surgery when TA is more than 2.3cm/m² or 4.2cm in A4C.