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BACKGROUND: Periprocedural and late (>30 days) bleedings represent major complications after transcatheter aortic valve replacement and have been identified as potential areas for improved patient care. OBJECTIVES: The authors sought to evaluate the impact of ongoing primary hemostasis disorders on late major/life-threatening bleeding complications (MLBCs). METHODS: Bleedings were assessed according to the VARC-2 (Valve Academic Research Consortium-2) criteria. Closure time of adenosine diphosphate (CT-ADP), a surrogate marker of high molecular weight von Willebrand multimers proteolysis was assessed 24 h after the procedure. Ongoing primary hemostasis disorder was defined by a CT-ADP >180 s. RESULTS: Among 372 patients who survived at 30 days, MLBCs occurred in 42 patients (11.3%) at a median follow-up of 383 days (interquartile range: 188 to 574 days). MLBCs were mainly of gastrointestinal origin (42.8%) and were associated with increased overall mortality (hazard ratio [HR]: 5.66; 95% confidence interval [CI]: 3.10 to 10.31; p < 0.001) and cardiac mortality (HR: 11.62; 95% CI: 4.59 to 29.37; p < 0.001). A 2.5-fold elevation of MLBCs could be evidenced in patients with a CT-ADP > 180 s (27.4% vs. 11.5%; p < 0.001). Multivariate regression analysis identified paravalvular leak (PVL) (HR: 6.31; 95% CI: 3.43 to 11.60; p < 0.0001) and CT-ADP > 180 s (HR: 3.08; 95% CI: 1.62 to 5.81; p = 0.0005) as predictor of MLBCs. CONCLUSIONS: MLBCs after transcatheter aortic valve replacement are frequent and associated with an increased morbidity and mortality. PVL and CT-ADP >180 s were identified as strong predictors for MLBCs. These findings strongly suggest that persistent HMW defects contribute to enhanced bleeding risk in patients with residual PVL.

Background and purpose—current guidelines recommend the use of transesophageal echocardiography (TEE) in relation to cardio-embolic sources of stroke. Methods—by using an hospital-based cohort, we retrospectively analyzed consecutive patients with acute ischemic stroke (AIS), acute hemorrhagic stroke (AHS) and transient ischemic attack (TIA) who were admitted in Strasbourg Stroke Center, France between November 2017 to December 2018. TEE reports were screened for detection of potential cardiac sources of embolism and the subsequent change in medical management. We performed univariate and multivariate analyses to identify predictors of relevant TEE findings. Results-out of the 990 patients admitted with confirmed stroke, 432 patients (42.6%) underwent TEE. Patients with TEE were younger (62.8 ± 14.8 vs. 73.8, p &lt, 0.001), presented less comorbidities and lower stroke severity assessed by lower NIHSS (2 IQR (0–4) vs. 3 IQR (0–10), p &lt, 0.01) and Modified Rankin Scale (1 IQR (0–1) vs. 1 (0–3), p &lt, 0.01). A total of 227 examinations (52.5%) demonstrated abnormal findings considered as potential cardiac sources of embolism and 31 examinations (7.1%) were followed by subsequent change in medical management. Age (HR: 0.948, 95% CI 0.923 to 0.974, p &lt, 0.001), previous AIS (HR: 3.542, 95% CI 1.290 to 9.722, p = 0.01), previous TIA (HR: 7.830, CI 95% 2214 to 27,689, p = 0.001) and superficial middle cerebral artery territory infarction (HR: 2.774, CI 95% 1.168–6.589, p = 0.021) were strong independent predictors with change in medical management following TEE. Conclusions—additional TEE changed the medical course of stroke patients in 7.1% in a French high-volume stroke unit.

Background Electrocardiographic strain pattern (ESP) has recently been associated with increased adverse outcome in aortic stenosis and after surgical aortic valve replacement. Our study sought to determine the impact and incremental value of ESP pattern in predicting adverse outcome after transcatheter aortic valve replacement. Methods and Results A total of 585 patients with severe aortic stenosis (mean age, 83±7 years; men, 39.8%) were enrolled for transcatheter aortic valve replacement from November 2012 to May 2018. ESP was defined as ≥1‐mm concave down‐sloping ST‐segment depression and asymmetrical T‐wave inversion in the lateral leads. The primary end points of the study were all‐cause mortality, rehospitalization for heart failure, myocardial infarction, and stroke. A total of 178 (30.4%) patients were excluded because of left bundle‐branch block (n=103) or right bundle‐branch block (n=75). Among the 407 remaining patients, 106 had ESP (26.04%). At a median follow‐up of 20.00 months (11.70–29.42 months), no impact of electric strain on overall and cardiac death could be established. By contrast, incidence of rehospitalization for heart failure was significantly higher (33/106 [31.1%] versus 33/301 [11%]; P P Conclusions In patients with aortic stenosis who were eligible for transcatheter aortic valve replacement, ESP is frequent and associated with an increased risk of postinterventional heart failure regardless of preoperative left ventricular hypertrophy. ESP represents an easy, objective, reliable, and low‐cost tool to identify patients who may benefit from intensified postinterventional follow‐up.

Background Acute kidney injury (AKI) is associated with a dismal prognosis in Transcatheter Aortic Valve replacement (TAVR). Acute kidney recovery (AKR), a phenomenon reverse to AKI has recently been associated with better outcomes. Methods Between November 2012 to May 2018, we explored consecutive patients referred to our Heart Valve Center for TAVR. AKI was defined according to the VARC-2 definition. Mirroring the VARC-2 definition of AKI, AKR was defined as a decrease in serum creatinine (≥50%) or ≥25% improvement in GFR up to 72 hours after TAVR. Results AKI and AKR were respectively observed in 8.3 and 15.7% of the 574 patients included. AKI and AKR patients were associated to more advanced kidney disease at baseline. At a median follow-up of 608 days (range 355–893), AKI and AKR patients experienced an increased cardiovascular mortality compared to unchanged renal function patients (14.6% and 17.8% respectively, vs. 8.1%, CI 95%, pp < 0.001) was the strongest independent factor associated with AKI similarly to baseline creatinine level (HR: 1; 95% CI 1 to 1.1 p < 0.001) for AKR. 72-hours post procedural AKR (HR: 2.26; 95% CI 1.14 to 4.88; p = 0.021) was the strongest independent predictor of CV mortality. Conclusions Both AKR and AKI negatively impact long term clinical outcomes of patients undergoing TAVR.

Acute kidney injury (AKI) following transcatheter aortic valve replacement (TAVR) is associated with a dismal prognosis. Elevated renal resistive index (RRI), through renal Doppler ultrasound (RDU) evaluation, has been associated with AKI development and increased systemic arterial stiffness. Our pilot study aimed to investigate the performance of Doppler based RRI to predict AKI and outcomes in TAVR patients. From May 2018 to May 2019, 100 patients with severe aortic stenosis were prospectively enrolled for TAVR and concomitant RDU evaluation at our institution (Nouvel H&ocirc, pital Civil, Strasbourg University, France). AKI by serum Creatinine (sCr-AKI) was defined according to the VARC-2 definition and AKI by serum Cystatin C (sCyC-AKI) was defined as an sCyC increase of greater than 15% with baseline value. Concomitant RRI measurements as well as renal and systemic hemodynamic parameters were recorded before, one day, and three days after TAVR. It was found that 10% of patients presented with AKIsCr and AKIsCyC. The whole cohort showed higher baseline RRI values (0.76 &plusmn, 0.7) compared to normal known and accepted values. AKIsCyC had significant higher post-procedural RRI one day (Day 1) after TAVR (0.83 &plusmn, 0.1 vs. 0.77 &plusmn, 0.6, CI 95%, p = 0.005). AUC for AKIsCyC was 0.766 and a RRI cut-off value of &ge, 0.795 had the most optimal sensitivity/specificity (80/62%) combination. By univariate Cox analysis, Mehran Risk Score, higher baseline right atrial pressure at baseline &gt, 0.8 RRI values one day after TAVR (HR 6.5 (95% CI 1.3&ndash, 32.9, p = 0.021) but not RRI at baseline were significant predictors of AKIsCyC. Importantly, no significant impact of baseline biological parameters, renal or systemic parameters could be demonstrated. Doppler-based RRI can be helpful for the non-invasive assessment of AKI development after TAVR.

Background Electrocardiographic (ECG) strain pattern has recently been associated with increased adverse outcome in aortic stenosis (AS) and after surgical aortic valve replacement (AVR). However, the relation linking ECG strain and cardiovascular MACE in patients with transcatheter aortic valve replacement (TAVR) has not been yet described. Objectives The aim of our study was to determine the impact and incremental value of ECG Strain pattern in predicting adverse outcome after TAVR. Methods 585 patients with severe AS (mean age: 83±7 male 39.8%) were enrolled from November 2012 to May 2018. ECG strain pattern was defined as ≥1 mm concave down-sloping ST-segment depression and asymmetrical T-wave inversion in the lateral leads. Patients with baseline left bundle branch block (LBBB), right bundle branch block (RBBB) or ventricular paced rhythm were excluded. All patients underwent transthoracic echocardiography (TTE) before TAVR and at 30 days follow up. The primary endpoints of the study were the overall all-cause mortality after TAVR, rehospitalization for Hearth failure (HF), myocardial infarction and stroke. Results 178 (30.4%) patients were excluded from analyses owing to the presence of either LBBB (n=103) or RBBB (n=75). Among the 407 remaining patients, 106 had ECG strain pattern (26.04%). Patients with ECG strain were significantly younger (81.6±8 years vs 83.5±6.8 years; p=0.022), had lower BMI (23±4.5 kg.m2 vs 27.9±6.8 kg.m2; p=0.02) more severe AS (mean gradient 52.3±15.2 mmHg vs 47.9±11.8 mmHg; p=0.003), significant lower LVEF (51.8±15% vs 58.4±10.7%; p Conclusion In patients with AS eligible for TAVR, ECG Strain Pattern is frequent and associated with an increased risk of post interventional heart failure regardless of preoperative LVH. ECG Strain pattern represents an easy, objective, reliable and low-cost tool to identify patients who may benefit from an extend and intensified post-interventional follow-up.

Background Paravalvular aortic regurgitation (PVAR) remains a frequent postprocedural concern following transcatheter aortic valve replacement (TAVR). Persistence of flow turbulence results in the cleavage of high-molecular-weight von Willebrand multimers, primary haemostasis dysfunction and may favour bleedings. Recent data have emphasized the value of a point-of-care measure of von Willebrand factor–dependent platelet function (closure time [CT] adenosine diphosphate [ADP]) in the monitoring of immediate PVAR. This study examined whether CT-ADP could detect PVAR at 30 days and bleeding complications following TAVR. Methods CT-ADP was assessed at baseline and the day after the procedure. At 30 days, significant PVAR was defined as a circumferential extent of regurgitation more than 10% by transthoracic echocardiography. Events at follow-up were assessed according to the Valve Academic Research Consortium-2 consensus classification. Results Significant PVAR was diagnosed in 44 out of 219 patients (20.1%). Important reduction of CT-ADP could be found in patients without PVAR, contrasting with the lack of CT-ADP improvement in significant PVAR patients. By multivariate analysis, CT-ADP > 180 seconds (hazard ratio [HR]: 5.1, 95% confidence interval [CI]: 2.5–10.6; p 180 seconds was identified as an independent predictor of major/life-threatening bleeding (HR: 1.7, 95% CI [1.0–3.1]; p = 0.049). Major/life-threatening bleedings were at their highest levels in patients with postprocedural CT-ADP > 180 seconds (35.2 vs. 18.8%; p = 0.013). Conclusion Postprocedural CT-ADP > 180 seconds is an independent predictor of significant PVAR 30 days after TAVR and may independently contribute to major/life-threatening bleedings.

Background Cardiovascular diseases and cancer are the two leading causes of mortality in the world and their association is a therapeutic challenge. Current data showed that patients with active cancer and severe aortic stenosis have better survival after aortic-valve replacement in comparison with those have medical treatment. Presence of active cancer is frequently a reason to decline surgery due to the fear of periprocedural complications in this frail population and transcatheter aortic-valve replacement (TAVR) appears like the treatment of choice in this situation. However, data concerning outcomes in this case are limited and contradictory. Purpose This study aims to constitute the first French cohort of patients with active cancer undergoing TAVR in order to determine their prevalence, characteristics, perioperative outcomes and mortality. Methods We prospectively included all consecutive patients who underwent TAVR in our institution (Nouvel Hopital Civil, Strasbourg, France). Active cancer status at the time of the procedure was determined by a specialist physician with an anatomopathological diagnosis in all cases where it was possible. Primary endpoint was all-cause mortality during follow-up. Results Among 585 patients who underwent TAVR, 62 had an active cancer. All-cause mortality was significantly higher in patients with active cancer in comparison with those without cancer (38.7% vs. 20.1% respectively; P = 0.001). This excess of mortality is mainly driven by non-cardiovascular causes of death. Other periprocedural complications (major adverse cardiovascular events, bleeding, rehospitalization for heart failure, acute kidney injury) did not differ between the two groups ( Fig. 1 ). Conclusion In patients who underwent TAVR, active cancer is a non-negligible comorbidity. All-cause mortality is higher in this population, mainly driven by non-cardiovascular mortality. However, periprocedural complications are not increased in this specific population.

Background Infective endocarditis (IE) remains a severe disease with a high mortality rate. Therefore, guidelines encourage the setup of a multidisciplinary group in reference centers. The present study evaluated the impact of this “Endocarditis Team” (ET). Methods We conducted a monocentric observational study at Strasbourg University Hospital, Strasbourg, France, between 2012 and 2017. The primary end point was in-hospital mortality. Secondary end points were 6-month and 1-year mortality, surgery rate, time to surgical procedure, duration of effective antibiotic therapy, length of in-hospital stay, and sequelae. We also assessed predictors of in-hospital mortality. Results We analyzed 391 episodes of IE. In the post-ET period, there was a nonsignificant decrease in in-hospital mortality (20.3% vs 14.7%, respectively; P = .27) and sequelae, along with a significant reduction in time to surgery (16.4 vs 10.3 days, respectively; P = .049), duration of antibiotic therapy (55.2 vs 47.2 days, respectively; P < .001), and length of in-hospital stay (40.6 vs 31.9 days, respectively; P < .01). In a multivariate analysis, the post-ET period was positively associated with survival (odds ratio, 0.45; 95% confidence interval, 0.20–0.96; P = .048). Conclusions This multidisciplinary approach exerted a positive impact on the management of IE and should be considered in all hospitals managing IE., The implementation of an 'Endocarditis Team' is recommended in reference centres for infective endocarditis. This study evaluated its impact and showed improvements on the management of this disease with a decrease in time to surgery and nonsignificant reduction in mortality.

Background and purpose Acute kidney injury (AKI) remains associated with a dismal prognosis in TAVR. Acute kidney recovery (AKR), a phenomenon reverse to AKI has recently been associated with better outcomes. Methods Between November 2012 to May 2018, we explored consecutive patients referred to our Heart Valve Center for TAVR. AKI was defined according to the VARC-2 definition. Mirroring the VARC-2 definition of AKI, AKR was defined as a decrease in serum creatinine (≥ 50%) or ≥ 25% improvement in GFR up to 72 hours after TAVR. Results AKI and AKR were respectively observed in 8.3 and 15.7% of the 574 patients included. AKI and AKR patients were associated to more advanced kidney disease at baseline. At a median follow-up of 608 days (range 355–893), AKI and AKR patients experienced an increased cardiovascular mortality compared to unchanged renal function patients (14.6% and 17.8% respectively, vs. 8.1%, CI 95%, P Fig. 1 ). Conclusions 72-hours post procedural AKR patients are a subgroup of patients at high risk of post TAVR cardiovascular complications

Contains fulltext : 167867.pdf (Publisher’s version ) (Closed access) BACKGROUND: The impact of prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) for aortic stenosis on exercise capacity remains controversial. The aim of this study was to analyze the long-term impact of PPM after mechanical AVR on maximal oxygen uptake (VO2max). METHODS: The study included 75 patients who had undergone isolated mechanical AVR for aortic stenosis with normal left ventricular (LV) function between 1994 and 2012. Their functional capacity was evaluated on average 4.6 years after AVR by exercise testing, including measurement of their VO2max, and by determining their New York Heart Association functional class and Short Form-36 score. Two groups were defined by measuring the patients' indexed effective orifice area (iEOA) by transthoracic echocardiography: a PPM group (iEOA < 0.85 cm2/m2) and a no-PPM group (iEOA >/= 0.85 cm2/m2). RESULTS: PPM was present in 37.0% of the patients. The percentage of the predicted VO2max achieved was significantly lower in the PPM group (86.7 +/- 19.5% vs 97.5 +/- 23.0% in the no-PPM group; P = 0.04). Compared with the no-PPM group, the PPM group contained fewer patients in New York Heart Association functional class I and their mean Short Form-36 physical component summary score was significantly lower. The mean transvalvular gradient was significantly higher in the PPM group than in the no-PPM group (P < 0.001). Systolic and diastolic function and LV mass had normalized in both groups. CONCLUSIONS: PPM is associated in the long term with moderate but significant impairment of functional capacity, despite optimal LV reverse remodelling and normalization of LV systolic and diastolic function.

Background Electrocardiographic (ECG) strain pattern (ESP) has recently been associated with increased adverse outcome in aortic stenosis (AS) and after surgical aortic-valve replacement (AVR). However, the relation linking ESP and cardiovascular MACE in patients with transcatheter aortic-valve replacement (TAVR) has not been yet described. Objectives Our study sought to determine the impact and incremental value of ESP pattern in predicting adverse outcome after TAVR. Methods A total of 585 patients with severe AS (mean age: 83 ± 7 years; male 39.8%) were enrolled for TAVR from November 2012 to May 2018. ESP was defined as ≥ 1 mm concave down-sloping ST-segment depression and asymmetrical T-wave inversion in the lateral leads. Patients with baseline left bundle branch block (LBBB), right bundle branch block (RBBB) or ventricular paced rhythm were excluded. The primary endpoints of the study were the overall all-cause mortality after TAVR, rehospitalization for hearth failure (HF), myocardial infarction and stroke. Results 178 (30.4%) patients were excluded owing to LBBB (n = 103) or RBBB (n = 75). Among the 407 remaining patients, 106 had ESP (26.04%). Patients with ESP were younger, had lower BMI and more severe AS and significant lower LVEF. At a median follow-up of 608 days (356–895), no impact of electric strain on overall and cardiac death could be established. By contrast, incidence of rehospitalization for HF was significantly higher (33 (31.1%) vs. 33 (11%); P Conclusion In patients with AS eligible for TAVR, ESP is frequent and associated with an increased risk of post interventional heart failure regardless of preoperative LVH. ESP represents an easy, objective, reliable and low-cost tool to identify patients who may benefit from intensified post-interventional follow-up.

Background Unfractionated heparin has been the standard anticoagulant used immediately after mechanical heart valve replacement (MHVR). The purpose of this study was to assess a postoperative anticoagulation protocol with low-molecular-weight heparin (LMWH) immediately after MHVR without the use of unfractionated heparin or anti-factor Xa monitoring. Methods We performed a prospective, single-center, observational study of 1,063 consecutive patients undergoing elective MHVR with postoperative LMWH anticoagulation treatment. The exclusion criteria were as follows: renal failure, intraaortic balloon counterpulsation, critical perioperative state, or a recent neurologic event. The postoperative anticoagulation protocol used subcutaneous enoxaparin as a bridging anticoagulant treatment beginning on the first postoperative day and continuing until vitamin K antagonist treatment was fully effective. Patients were followed for 6 weeks. The primary endpoints were the incidence of thromboembolic or major bleeding events. Results Eleven (1%) thromboembolic events occurred. Ten of these events were transient or permanent strokes. Major bleeding events occurred in 44 patients (4.1%), 7 of which were observed before the enoxaparin treatment period. At the time of discharge, 570 patients (53.6%) were no longer receiving LMWH treatment due to achieving the target international normalized ratio. The mean length of hospital stay was 8.5 ± 2.9 days. There were no deaths during the 6-week follow-up period. Conclusions In our highly selected population, after MHVR, postoperative anticoagulation using LMWH is associated with a low rate of thromboembolic and major bleeding events. This large observational study demonstrates that the use of LMWH as an anticoagulant is effective and safe after MHVR.

Background Paravalvular aortic regurgitation (PAVR) remains a frequent post-procedural concern following transcatheter aortic valve replacement (TAVR). Persistence of flow turbulence results in the cleavage of high molecular weight von Willebrand multimers, primary hemostasis dysfunction and may favour bleedings. Recent data have emphasized the value of a point-of-care measure of von Willebrand factor-dependent platelet function (closure-time (CT)-ADP) in the monitoring of immediate PA. This study examined whether CT-ADP could detect PAVR at 30 days and bleeding complications following TAVR. Methods CT-ADP was assessed at baseline and the day after the procedure. At 30 days, significant PAVR was defined as a circumferential extent of regurgitation greater than 10% by transthoracic echocardiography. Events at follow-up were assessed according to the VARC-2 classification. Results Significant PAVR was diagnosed in 44/219 patients. Important reduction of CT-ADP could be found in patients without PAVR, contrasting with the lack of CT-ADP improvement in significant PAVR patients. By univariate analysis, a self-expendable valve, valve size ≥ 31 mm and CT-ADP > 180 s were associated with PAVR. By multivariate analysis, CT-ADP > 180 s (HR 5.1 95% CI (2.5–10.6); P 180 s, but not PAVR, was proven to be an independent predictor of major/life-threatening bleeding (HR 1.813 (1.014–3.241); P = 0.045) [ Table 1 , Fig. 1 ]). Conclusion Post-procedural CT-ADP > 180 s is an independent predictor of significant PAVR 30 days after TAVR and may independently contribute to major/life-threatening bleedings. Other parameters such LVEF should be taken into account in the interpretation of prolonged CT-ADP time following valve implantation.

Objectives Prosthesis-patient mismatch (PPM) has been reported to impact early haemodynamic status and early mortality after prosthetic aortic valve replacement (AVR) in patients with aortic stenosis (AS). The aim of this study was to assess the impact of PMM on early haemodynamic status after AVR using vasoactive-inotropic dependency index (VDI), postoperative pressures and end-organ perfusion. Methods A total of 183 patients with AS were included in this prospective cohort study, and underwent elective AVR with or without combined coronary artery bypass graft surgery. PPM was defined as a projected indexed effective orifice area of ≤0.85 cm2/m2, and was present in 27.9% of the patients. The primary end-point was the VDI [VDI = vasoactive-inotropic score/mean arterial pressure] measured upon admission to the intensive care unit (POD0) and on the morning of the first postoperative day (POD1). The secondary end-points were the following: mean left atrial pressure, mean central venous pressure, fluid balance, brain natriuretic peptide, troponin I, glomerular filtration rate and lactate levels on POD0 and POD1. Results No significant differences in VDI were observed between the no PPM and PPM groups on POD0 (0.08 ± 0.48 vs 0.05 ± 0.13, respectively, P = 0.622) or on POD1 (0.09 ± 0.40 vs 0.06 ± 0.13, respectively; P = 0.583). The mean arterial pressure, mean left atrial pressure, central venous pressure, troponin I, glomerular filtration rate and lactate levels did not differ between the two groups on POD0 and POD1, as well as fluid balance and brain natriuretic peptide on POD1. Conclusions PPM is not associated with early haemodynamic status impairment and end-organ perfusion after AVR. Clinical trial number ClinicalTrials.gov number, NCT00699673.

International audience; Background: We have been intrigued by the observation that aortic stenosis (AS) may be associated with characteristic features of mitral drug-induced valvular heart disease (DI-VHD) in patients exposed to valvulopathic drugs, thus suggesting that beyond restrictive heart valve regurgitation, valvulopathic drugs may be involved in the pathogenesis of AS. Methods: Herein are reported echocardiographic features, and pathological findings encountered in a series of patients suffering from both AS (mean gradient > 15 mm Hg) and mitral DI-VHD after valvulopathic drugs exposure. History of rheumatic fever, chest radiation therapy, systemic disease or bicuspid aortic valve disease were exclusion criteria. Results: Twenty-five (19 females, mean age 62 years) patients having both AS and typical features of mitral DI-VHD were identified. Mean transaortic pressure gradient was 32+/-13 mm Hg. Aortic regurgitation was >= mild in 24 (96%) but trivial in one. Known history of aortic valve regurgitation following drug initiation prior the development of AS was previously diagnosed in 17 patients (68%). Six patients underwent aortic valve replacement and 3 both aortic and mitral valve replacement. In the 9 patients with pathology analysis, aortic valvular endocardium was markedly thickened by dense non-inflammatory fibrosis, a characteristic feature of DI-VHD. Conclusion: The association between AS and typical mitral DI-VHD after valvulopathic drug exposure may not be fortuitous. Aortic regurgitation was usually associated to AS and preceded AS in most cases but may be lacking. Pathology demonstrated the potential role of valvulopathic drugs in the development of AS. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

In the setting of low-flow/low-gradient aortic stenosis (LF/LGAS), outcomes of pseudo-severe aortic stenosis (AS) remain poorly described. This study was aimed to assess the outcome of patients with pseudo-severe AS under conservative treatment.Among 305 patients from the European Registry of LF/LGAS, the outcomes of the 107 patients followed under conservative treatment were analysed. Based on the results of dobutamine echocardiography, patients were divided into group IA [left ventricular (LV) contractile reserve present with true-severe AS, n = 43], group IB [pseudo-severe AS (n = 29) defined as LV contractile reserve with a final aortic valve area ≥1.2 cm(2) and a mean transaortic pressure gradient40 mmHg at peak dobutamine infusion], or group II (exhausted LV contractile reserve, n = 35). The rate of death within 5 years was significantly lower in the group IB (43 ± 11%, n = 10), when compared with the group IA (91 ± 6%, n = 33; P = 0.001) and the group II (100%, n = 23; P0.001). The Cox proportional hazard model analysis demonstrated that the hazard ratio for death in the group IB remained significantly lower than in the other groups, even after adjustment for currently established risk factors. Furthermore, the 5-year survival of pseudo-severe AS patients was comparable with that of propensity-matched patients with systolic heart failure and no evidence of valve disease.In patients with pseudo-severe AS, the 5-year survival under conservative treatment is better than in true-severe AS and comparable with that of propensity-matched patients with LV systolic dysfunction and no evidence of valve disease. Further studies are needed to define optimal therapeutic management in these patients.

Objectives In a multicentre series of patients with low-ejection fraction/low-gradient aortic stenosis (LEF/LGAS), we evaluated the prognostic impact of valvuloarterial impedance (Zva). Background Zva in AS, a measure of global afterload taking into account systemic arterial compliance, has been proposed for risk stratification in paradoxical LGAS. We hypothesized that Zva could help risk stratification in LEF/LGAS. Methods and results We retrospectively calculated Zva (5.6 ± 1.7 mmHg/mL/m2) of 184 consecutive patients (mean age: 71 ± 10 years) with severe symptomatic LEF/LGAS (valve area ≤1 cm², EF ≤40%, mean transaortic pressure gradient ≤40 mmHg) included between 1995 and 2005 in a multicentre registry. Zva was higher in patients with LVEF at rest ≤20% (6.6 ± 2.3 vs. 5.5 ± 1.6; P = 0.05) and correlated negatively with LVEF at rest ( R = −0.25; P = 0.001). Zva was lower in patients without contractile reserve (CR) on dobutamine stress echocardiography (DSE) compared with patients with true severe AS (5.3 ± 1.3 vs. 5.8 ± 1.8 mmHg/mL/m2; P = 0.048). Zva and the variation in stroke volume during DSE were positively correlated ( P = 0.0001) but Zva did not allow distinction between true and pseudo-severe AS (5.8 ± 1.8 vs. 5.3 ± 1.8mmHg/mL/m2; P = 0.30). In the total population, Zva was not predictive of long-term mortality. In the 128 patients who underwent aortic valve replacement, Zva was not predictive of operative death and of long-term mortality. Conclusions Increased Zva is related to low LVEF and more frequent CR on DSE in LEF/LGAS. However, Zva did not allow an accurate distinction between true and pseudo-severe AS and failed to predict operative and long-term mortality after aortic valve replacement, in LEF/LGAS.

ObjectivesThis study investigated whether aortic valve replacement (AVR) is associated with improved survival in patients with severe low-flow/low-gradient aortic stenosis (LF/LGAS) without contractile reserve (CR) on dobutamine stress echocardiography (DSE).BackgroundPatients with LF/LGAS without CR have a high mortality rate with conservative therapy. The benefit of AVR in this subset of patients remains controversial.MethodsEighty-one consecutive patients with symptomatic calcified LF/LGAS (valve area ≤1 cm2, left ventricular ejection fraction ≤40%, mean pressure gradient [MPG] ≤40 mm Hg) without CR on DSE were enrolled. Absence of CR was defined as the absence of increase in stroke volume of ≥20% compared with the baseline value. Multivariable analysis and propensity scores were used to compare survival according to whether or not AVR was performed (n = 55).ResultsFive-year survival was higher in AVR patients compared with medically managed patients (54 ± 7% vs. 13 ± 7%, p = 0.001) despite a high operative mortality of 22% (n = 12). An AVR was independently associated with lower 5-year mortality (adjusted hazard ratio from 0.16 to 5.21 varying with time [95% confidence interval: 0.12–3.16 to 0.21–8.50], p = 0.00026). In 42 propensity-matched patients, 5-year survival was markedly improved by AVR (65 ± 11% vs. 11 ± 7%, p = 0.019). Associated bypass surgery (p = 0.007) and MPG ≤20 mm Hg (p = 0.035) were independently predictive of operative mortality. Late survival after AVR (excluding operative death) was 69 ± 8% at 5 years.ConclusionsIn patients with LF/LGAS without CR on DSE, AVR is associated with better outcome compared with medical management. Surgery should not be withheld from this subset of patients solely on the basis of lack of CR on DSE.

Objectives We evaluated a large multicenter series of patients operated on for low-flow/low-gradient aortic stenosis (LF/ LGAS) to stratify the operative risk, assess whether perioperative mortality has decreased over recent years, and analyze the post-operative outcome. Background Although LF/LGAS is classically associated with a high operative risk, few data are available concerning the results of surgery in this setting. Methods A total of 217 consecutive patients (168 men, 77%) with severe aortic stenosis (area

BackgroundAortic valve stenosis (AVS) can be complicated by bleeding associated with acquired type 2A von Willebrand syndrome. The association of AVS and gastrointestinal bleeding from angiodysplasia is defined as Heyde’s syndrome. We sought to evaluate the impact of TAVI on primary hemostasis disorders and to assess its effectiveness to treat Heyde’s syndrome.MethodsWe prospectively enrolled 49 consecutive patients with severe AVS referred to our institution for TAVI. Biological primary hemostasis parameters were assessed at baseline and one week after the procedure.ResultsAt baseline, a significant link between vWF abnormalities and the severity of AVS was evidenced: mean aortic transvalvular gradient was negatively correlated with the levels of vWF antigen (vWF: Ag) (r=–0.29, p

Aortic valve stenosis (AVS) can be complicated by bleeding associated with acquired type 2A von Willebrand syndrome. The association of AVS and gastrointestinal bleeding from angiodysplasia is defined as Heyde syndrome. We sought to evaluate the effect of transcutaneous aortic valve implantation (TAVI) on hemostasis disorders and to assess its effectiveness to treat Heyde syndrome.We prospectively enrolled 49 consecutive patients with severe AVS addressed for TAVI at our institution. Biological hemostasis parameters involving von Willebrand factor (vWF) were assessed at baseline and 1 week after the procedure.At baseline, a significant link between vWF abnormalities and the severity of AVS was evidenced: mean aortic transvalvular gradient was negatively correlated with the levels of vWF antigen (vWF:Ag) (r = -0.29; P0.05), vWF ristocetin cofactor activity (r = -0.402; P = 0.006), and vWF collagen-binding activity (vWF:CB; r = -0.441; P = 0.005). One week after the procedure, a significant increase of vWF:Ag, vWF ristocetin cofactor activity, and vWF:CB was evidenced in the whole cohort (respectively, 3.32 vs. 2.29 IU/mL, P0.001; 2.98 vs. 1.86 IU/mL, P0.001; and 3.16 vs. 2.16 IU/mL, P0.001). Patients with pre-TAVI vWF abnormalities consistent with a type 2A vWF syndrome (ratio vWF:CB/vWF:Ag0.7) preferentially improved their vWF function with respect to patients with a normal ratio (relative increase of vWF:CB of 63.8% vs. 3.5%).Hemostasis parameters involving vWF are improved after TAVI, especially in patients with pre-existing abnormalities consistent with acquired type 2A von Willebrand syndrome.

IntroductionLeft atrium (LA) structural remodeling associated with atrial fibrillation (AF) contributes to recurrence after AF catheter ablation (CA). Characterizing LA function may be useful to identify patients with higher risk of recurrence and could guide ablation strategy in term of substrate modification. We aimed to identify predictors of recurrence and atrial remodeling by assessing LA and left ventricle (LV) deformation properties using two-dimensional speckle-tracking imaging before and after AF CA.Methods62 patients (age 54±10 years, 90% male) with AF (45 paroxysmal (PAF), 17 persistent (PsAF)) underwent an echocardiography before CA, 3 and 6 months after CA to assess LA strain (S total (S-tot), positive peak (S-pos), negative peak (S-neg)), LA strain rate (SR positive peak (SRs), early (SRe) and late negative peak (SRa)) and LV strain (LV longitudinal and radial S).ResultsPsAF patients baseline had significantly larger LA volumes (41±8 vs 32±10ml/m2), decreased S-tot (10±5 vs 20±6%; p

Aims To assess the prognostic impact of prosthesis-patient mismatch (PPM) in a large consecutive series of patients operated for low-gradient aortic stenosis (AS). Methods and results Outcomes after surgery for low-gradient AS were prospectively assessed in 152 consecutive patients from seven institutions. There were 113 men (74%); mean age was 72 years (64–76); valve area, 0.7 cm2 (0.6–0.8); left ventricular (LV) ejection fraction 0.31 (0.25–0.37) and baseline mean transaortic pressure gradient (MPG), 30 mmHg (25–35) Among 139 patients with available prosthetic valve effective orifice area (EOA), PPM (defined by an indexed EOA ≤ 0.85 cm2/m2) was present in 79 patients (57%) and had no significant impact on post-operative mortality. Independent predictors of overall mortality were LV contractile reserve [hazard ratio (HR) 0.52; 95% confidence interval (CI) 0.35–0.78; P = 0.002], associated coronary artery bypass grafting (HR 1.87; 95% CI 1.24–2.82; P =0.003), baseline MPG (per 1 mmHg decrease to 10 mmHg; HR 1.03; 95% CI 1.01–1.06; P = 0.021), previous cancer (HR 2.13; 95% CI 1.05–4.29; P = 0.037), and logistic EuroSCORE (per 1% increase; HR 1.02; 95% CI 1.01–1.04; P = 0.040). Conclusion In this large multicentre series of patients with low-gradient AS, we found that PPM (moderate in most cases) had no influence on post-operative mortality. Therefore, the performance of more complex interventions in order to avoid moderate PPM may not be justified in the setting of low-gradient AS, because their higher risk probably outweighs the expected benefit.

We evaluated a large multicenter series of patients operated on for low-flow/low-gradient aortic stenosis (LF/LGAS) to stratify the operative risk, assess whether perioperative mortality has decreased over recent years, and analyze the post-operative outcome.Although LF/LGAS is classically associated with a high operative risk, few data are available concerning the results of surgery in this setting.A total of 217 consecutive patients (168 men, 77%) with severe aortic stenosis (area1 cm(2)), low ejection fraction (EF) (or=35%), and low mean gradient (MG) (or=30 mm Hg) who underwent aortic valve replacement (AVR) between 1990 and 2005 were included.Perioperative mortality was 16% and decreased dramatically from 20% in the 1990 to 1999 period to 10% in the 2000 to 2005 period. Higher European System for Cardiac Operative Risk Evaluation score (EuroSCORE), very low MG and EF, New York Heart Association functional class III or IV, history of congestive heart failure, and multivessel coronary artery disease (MVD) were associated with perioperative mortality. On multivariate analysis, very low pre-operative MG and MVD were predictors of excess perioperative mortality. In the subgroup of patients with dobutamine stress echocardiography, the absence of contractile reserve was a strong predictor of perioperative mortality. Overall 5-year survival rate was 49 +/- 4%. Lower MG, higher EuroSCORE, prior atrial fibrillation, and MVD were identified as independent predictors of overall long-term mortality.In view of the very poor prognosis of unoperated patients, the current operative risk, and the long-term outcome after surgery, AVR is the treatment of choice in the majority of cases of LF/LGAS.

Aortic valve stenosis (AVS) can be complicated by bleeding associated with acquired type 2A von Willebrand syndrome. The association of AVS and gastrointestinal bleeding from angiodysplasia is defined as Heyde's syndrome. We sought to evaluate the impact of TAVI on primary hemostasis disorders and