Search

Valvular heart disease (VHD) is the next epidemic in the cardiovascular field, affecting millions of people worldwide and having a major impact on health care systems. With aging of the population, the incidence and prevalence of VHD will continue to increase. However, VHD has not received the attention it deserves from both the public and policymakers. Despite important advances in the pathophysiology, natural history, management, and treatment of VHD including the development of transcatheter therapies, VHD remains underdiagnosed, identified late, and often undertreated with inequality in access to care and treatment options, and there is no medication that can prevent disease progression. The present review article discusses these gaps in the management of VHD and potential actions to undertake to improve the outcome of patients with VHD.

Background: Patients with low left ventricular ejection fraction (LVEF), low-flow, low-gradient (i.e. classical low flow [CLF]) aortic stenosis (AS) have a dismal short-term outcome without aortic ...

Background: Multiple studies have examined the prevalence of left atrial appendage thrombus (LAAT) in patients anticoagulated with direct oral anticoagulants (DOACs) and have reported conflicting results. Methods: Studies reporting the prevalence of LAAT on transesophageal echocardiography (TEE) after 3 or more weeks of DOAC therapy were identified. The proportions of anticoagulated patients diagnosed with LAAT were pooled using random-effects models. Prespecified subgroup analyses by the indication of TEE (pre–atrial fibrillation [AF] ablation vs cardioversion) and TEE strategy (routine use vs selective) were conducted via stratification. Results: Forty studies were identified: 22 full manuscripts and 18 abstracts. Only 11 studies performed TEE routinely. Most studies included patients with paroxysmal AF and low thromboembolic risk. The pooled prevalence of LAAT was 2.5% (95% confidence interval [1.6%-3.4%]). The prevalence of LAAT is lower in the pre-AF ablation group compared with pre-cardioversion (1.1% vs 4.0%, P = 0.033). Routine TEE strategy yielded a lower LAAT prevalence in both groups (0.1% vs 2.3%, P = 0.002 and 3.2% vs 5.8%, P = 0.432, respectively). Conclusion: The reported prevalence of LAAT on TEE in patients treated with DOACs is highly variable. Factors associated with a high LAAT prevalence were pre-cardioversion indication and selective TEE strategy. Routine use of TEE before AF ablation may not be warranted. Résumé: Introduction: De nombreuses études ont porté sur la prévalence des thrombi se formant dans l’appendice auriculaire gauche (TAAG) chez les patients qui reçoivent des anticoagulants oraux directs (AOD) et ont révélé des résultats contradictoires. Méthodes: Nous avons recensé les études qui ont fait état de la prévalence des TAAG à l’échocardiographie transœsophagienne (ETO) trois semaines ou plus après le traitement par AOD. Les modèles à effets aléatoires ont permis de regrouper les patients qui prenaient des anticoagulants et avaient reçu un diagnostic de TAAG. Nous avons réalisé les analyses de sous-groupes prédéterminés par l’indication d’ETO (fibrillation auriculaire [FA] avant l’ablation vs FA avant la cardioversion) et la stratégie d’utilisation de l’ETO (systématique vs sélective) grâce à la stratification. Résultats: Nous avons recensé 40 études : 22 manuscrits complets et 18 résumés. Seules 11 études portaient sur l’utilisation systématique de l’ETO. La plupart des études portaient sur des patients qui étaient atteints de FA paroxystique et exposés à un faible risque thromboembolique. La prévalence groupée de TAAG était de 2,5 % (intervalle de confiance à 95 % [1,6 %-3,4 %]). La prévalence de TAAG était plus faible dans le groupe de FA avant l’ablation que dans le groupe de FA avant la cardioversion (1,1 % vs 4,0 %, P = 0,033). La stratégie d’utilisation systématique de l’ETO a permis d’obtenir une prévalence plus faible de TAAG dans les deux groupes (0,1 % vs 2,3 %, P = 0,002 et 3,2 % vs 5,8 %, P = 0,432, respectivement). Conclusion: La prévalence de TAAG à l’ETO chez les patients traités par AOD varie beaucoup. Les facteurs associés à une prévalence élevée de TAAG étaient l’indication avant la cardioversion et la stratégie d’utilisation sélective de l’ETO. L’utilisation systématique de l’ETO avant l’ablation peut ne pas être justifiée.

Cardiac sympathetic nervous system (SNS) dysfunction is associated with poor prognosis in chronic heart failure patients. This study characterized the reproducibility and repeatability of [11C]meta-hydroxyephedrine (HED) positron emission tomography (PET) quantification of cardiac SNS innervation, regional denervation, and myocardial blood flow (MBF). Dynamic HED PET-CT scans were performed 47 ± 22 days apart in 20 patients with stable heart failure and reduced ejection fraction. Three observers, blinded to clinical data, used FlowQuant® to evaluate the test-retest repeatability and inter- and intra-observer reproducibility of HED tracer uptake and clearance rates to measure global (LV-mean) retention index (RI), volume of distribution (VT), and MBF. Values were also compared with and without regional partial-volume correction. Regional denervation was quantified as %LV defect size of values

Valvular heart disease (VHD) is responsible for a major societal and economic burden. Incidence and prevalence of VHD are high and increase as the population ages, creating the next epidemic. In Western countries, the etiology is mostly degenerative or functional disease and strikes an elderly population with multiple comorbidities. Epidemiological studies have shown that VHD is commonly underdiagnosed, leading to patients presenting late in their disease course, to an excess risk of mortality and morbidity and to a missed opportunity for intervention. Once diagnosed, VHD is often undertreated with patients unduly denied intervention, the only available curative treatment. This gap between current recommendations and clinical practice and the marked under-treatment is at least partially related to poor knowledge of current National and International Societies Guidelines. Development of a valvular heart team involving multidisciplinary valve specialists including clinicians, imaging specialists, interventional cardiologists and surgeons is expected to fill these gaps and to offer an integrated care addressing all issues of patient management from evaluation, risk-assessment, decision-making and performance of state-of-the-art surgical and transcatheter interventions. The valvular heart team will select the right treatment for the right patient, improving cost-effectiveness and ultimately patients’ outcomes.

The natural history of mitral annular calcification (MAC) and risk for developing calcific mitral valve disease (CMVD) have been poorly defined. The aim of this study was to evaluate the progression rate of MAC and of the development of CMVD.Patients with MAC and paired echocardiograms ≥1 year apart between 2005 and 2019 were included. Progression rates from mild or moderate to severe MAC and to CMVD (defined as severe MAC and significant mitral stenosis and/or regurgitation) were assessed, along with potential association with sex.A total of 11,605 patients (mean age, 73 ± 10 years; 51% men) with MAC (78% mild, 17% moderate, 5% severe) were included and underwent follow-up echocardiography at 4.2 ± 2.7 years. Among patients with mild or moderate MAC, 33% presented with severe MAC at 10 years. The rate of severe MAC was higher in women than in men (41% vs 24% [P .001]; hazard ratio, 1.3; P .001) and in patients with moderate versus mild MAC (71% vs 22% [P .001]; hazard ratio, 6.1; P .001). At 10 years, 10% presented with CMVD (4%, 23%, and 60% in patients with mild, moderate, and severe MAC, respectively), which was predicted by female sex (15% vs 5%; P .0001), even after adjustment for MAC severity (hazard ratio, 1.9; P .001).In this large cohort of patients with MAC, progression to severe MAC was common and frequently resulted in CMVD. Female sex was associated with higher progression rates. MAC and CMVD are expected to dramatically increase as the population ages, highlighting the importance of a better understanding of the pathophysiology of MAC to develop effective preventive medical therapies.

Little is known about the prevalence, presentation and management of calcific mitral valve disease (CMVD). We identified 167 patients (80 ± 10 years; 79% women) with significant CMVD undergoing transthoracic echocardiography at our institution in 2016. Patients presented with significant co-morbidities, 47% had moderate/severe mitral stenosis, 38% had 3+/4+ mitral regurgitation and 15% had a combination of both. Fifty-eight percent were symptomatic. Most symptomatic patients were managed conservatively and incurred higher mortality and mortality/heart failure admission rates than those managed surgically. These data highlight the importance of gaining mechanistic insights into CMVD to prevent its occurrence and avoid the need for high-risk surgery, which is seldom performed in contemporary practice.

BACKGROUND There are discrepancies in the quantitative echocardiographic criteria for the right ventricle (RV) between the revised task force criteria (TFC) for Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia (ARVC/D) and the guidelines for RV assessment endorsed by American Society of Echocardiography (ASE). Importantly, these criteria do not take into account potential adaptation of the RV to exercise. The goal of this study was to compare the revised TFC quantitative echocardiographic parameters in patients with ARVC/D, athletes and matched controls. METHODS Echocardiographic parameters of the RV were retrospectively collected in patients who fulfilled the TFC for ARVC/D, an age- matched, sex-matched, and body surface area-matched control population, and athletes (defined as individuals who exercised for more than 7 hours per week). Patients with structural heart disease were excluded in the control and athlete groups. RESULTS Twenty patients with ARVC/D, 11 athletes and 20 matched controls were included. There was no significant difference between ARVC/D patients and athletes with the exception of the parasternal long axis right ventricular outflow tract diameter. All parameters were significantly different between ARVC/D patients and the control group. Furthermore, when subjects were categorized into meeting 1 major revised TFC/abnormal ASE criteria or not, only ASE criteria were able to differentiate ARVC/D from control population. Both were unable to differentiate ARVC/D from athletes. CONCLUSIONS Right ventricle quantitative echocardiographic criteria in the revised TFC are not specific for ARVC/D. Care should be taken in applying these criteria in athletes.

Clinical management of patients with only moderate aortic stenosis (AS) but symptoms of heart failure with a reduced left ventricular ejection fraction (HFrEF) is challenging. Current guidelines recommend clinical surveillance with multimodality imaging; aortic valve replacement (AVR) is deferred until the stenosis becomes severe. Given the known benefits of afterload reduction in management of patients with HFrEF, it has been hypothesized that AVR may be beneficial in patients with only moderate AS who present with HFrEF. In this article, we first review the current approach for management of patients with moderate AS and HFrEF based on close clinical and imaging surveillance with AVR delayed until AS is severe. We then discuss the case for transcatheter AVR (TAVR) earlier in the disease course, when AS is moderate, based on stress echocardiographic data. We conclude with a detailed summary of the TAVR UNLOAD (Transcatheter Aortic Valve Replacement to UNload the Left Ventricle in Patients With ADvanced Heart Failure) trial, in which patients with moderate AS and HFrEF are randomized to guideline-directed heart failure therapy alone versus guideline-directed heart failure therapy plus TAVR.

Aims Transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) has profoundly changed the management of patients with aortic valve stenosis (AS). Large unbiased nationwide data regarding TAVR implementation, impact on SAVR and their respective outcomes are scarce. Methods and results Based on a French administrative hospital-discharge database, we collected data on all consecutive aortic valve replacements (AVRs) performed in France for AS between 2007 and 2019 [106 253 isolated SAVR (49%), 46 514 combined SAVR (21%), and 65 651 TAVR (30%)]. The number of AVR linearly increased between 2007 and 2019 (from 10 892 to 23 109, P for trend < 0.0001) due to a marked increase in TAVR (from 253 to 13 030, P for trend < 0.0001), while SAVR increased up to 2013 and then declined (10 892 in 2007, 12 699 in 2013, and 10 079 in 2019). The Charlson index decreased linearly for TAVR, but in two steps for SAVR (2011 and 2017). In-hospital mortality rates of both SAVR and TAVR declined (both P for trend < 0.0001) and were similar or lower for TAVR than for isolated SAVR in patients 75 years or above in the last 3 years (2017–19). Complication rates of TAVR also declined but permanent pacemaker rates remained high and length of stay substantial (16.7% and median 6 days, respectively, in 2017–19). Conclusion The number of AVR has doubled in a decade and TAVR has become the dominant form of AVR in 2018. The improvement in patient profiles seems to have anticipated the demonstrated benefit of TAVR in intermediate and low-risk patients. In patients 75 years or older, TAVR should be considered as the first option. We also highlight two important areas for improvement, the high permanent pacemaker rates, and the long length of stay even in the contemporary era. Our results may have major implications for clinical practice and policymakers.

BACKGROUND Mitral annular calcification (MAC) is a common finding, but the natural history and risk for developing calcific mitral valve disease (CMVD) have been poorly defined. We sought to evaluate the progression rate of MAC and of the development of CMVD. METHODS AND RESULTS Patients with at least mild MAC and paired echocardiograms at least one year apart between 2005 and 2019 were included. Progression rates from mild/moderate MAC to severe MAC and to CMVD (defined as severe MAC and significant mitral stenosis and/or regurgitation) were assessed, along with potential associations with sex and aortic valve stenosis (AS) progression. A total of 11,605 patients (73±10 years, 51% male) with MAC (78% mild, 17% moderate, 5% severe) were included and had a follow up echocardiogram at 4.2±2.7 years. In patients with mild/moderate MAC on their initial echocardiogram, the incidence of severe MAC at 10 years was 33%. The incidence was higher in females than in males (41% vs. 24%, P CONCLUSION In this large patient cohort with MAC, progression to severe MAC is common and frequently results in CMVD. Female sex was associated with higher progression rates and an association between MAC and AS progression was observed. MAC and CMVD are expected to dramatically increase as the population ages and there is an urgent need to better understand the pathophysiology of MAC in order to develop effective preventative medical therapies.

Background No randomized comparison of early (ie, ≤3 months) aortic valve replacement (AVR) versus conservative management or of transcatheter AVR (TAVR) versus surgical AVR has been conducted in patients with low‐flow, low‐gradient (LFLG) aortic stenosis (AS). Methods and Results A total of 481 consecutive patients (75±10 years; 71% men) with LFLG AS (aortic valve area ≤0.6 cm 2 /m 2 and mean gradient P P =0.01), and in classic (HR, 0.33 [95% CI, 0.22–0.49]; P P =0.03). Compared with conservative management in the conventional multivariate model, trans femoral TAVR was associated with the best survival (HR, 0.23 [95% CI, 0.12–0.43]; P P P =0.007). In the inverse probability of treatment weighting model, trans femoral TAVR appeared to be superior to surgical AVR (HR [95% CI] 0.28 [0.11–0.72]; P =0.008) with regard to survival. Conclusions In this large prospective observational study of LFLG AS, early AVR appeared to confer a major survival benefit in both classic and paradoxical LFLG AS. This benefit seems to extend to the subgroup with pseudo‐severe AS. Our findings suggest that TAVR using femoral access might be the best strategy in these patients. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01835028.

Aims Severe aortic valve stenosis (AS) is defined by an aortic valve area (AVA) Methods and results In 1298 patients with degenerative AS and preserved ejection fraction from three different countries and continents (derivation cohort), we aimed to establish an AVA/H threshold that would be equivalent to 1.0 cm2 for defining severe AS. In a distinct prospective validation cohort of 395 patients, we compared the predictive accuracy of AVA/BSA and AVA/H. Correlations between AVA and AVA/BSA or AVA/H were excellent (all R2 > 0.79) but greater with AVA/H. Regressions lines were markedly different in obese and non-obese patients with AVA/BSA (P Conclusion In a large multinational/multiracial cohort, AVA/H was better correlated with AVA than AVA/BSA and a cut-off value of 0.6 cm2/m provided a better diagnostic and prognostic value than 0.6 cm2/m2. Our results suggest that severe AS should be defined as an AVA < 1 cm2 or an AVA/H

International audience; BACKGROUND: Growing evidence shows a major outcome impact and under-treatment of tricuspid regurgitation (TR) but large and comprehensive contemporary reports of management and outcome at the nationwide level are lacking. METHODS: We gathered all consecutive patients admitted with a diagnosis of likely functional TR in 2014-2015 in France from the "Programme de Médicalisation des Systèmes d'Information" (PMSI) national database and collected rate of surgery, in-hospital mortality, one-year mortality or heart failure (HF) readmission rates. RESULTS: In 2014-2015, 17,676 consecutive patients (75±14 years, 51% female) were admitted with a TR diagnosis. Charlson index was ≥2 in 56% of the population and 46% presented with heart failure. TR was associated with prior cardiac surgery, ischemic/dilated cardiomyopathy or mitral regurgitation in 73% of patients. Only 10% of TR patients overall and 67% of those undergoing a mitral valve surgery received a tricuspid valve intervention. Among the 13,654(77%) conservatively managed patients, in-hospital mortality, one-year mortality and one-year mortality or HF readmission rates were 5.1%,17.8% and 41% respectively overall and 5.3%,17.2% and 37% respectively in those no underlying medical conditions (8-times higher than predicted for age and gender). CONCLUSION: This nationwide cohort of patients admitted with TR included elderly patients with frequent comorbidities/underlying cardiac diseases. In patients conservatively managed, mortality and morbidity were considerably high over a short time-span. Despite this poor prognosis only 10% of patients underwent a tricuspid valve intervention. These nationwide data showing a considerable risk and potential underuse of treatment highlight the critical need to develop strategies to improve the management and outcomes of TR patients.

Background Although US recent data suggest that mitral regurgitation (MR) is severely undertreated and carries a poor outcome, population‐based views on outcome and management are limited. We aimed to define the current treatment standards, clinical outcomes, and costs related to MR at the nationwide level. Methods and Results In total, 107 412 patients with MR were admitted in France in 2014 to 2015. Within 1 year, 8% were operated and 92% were conservatively managed and constituted our study population (68% primary MR and 32% secondary MR). The mean age was 77±15 years; most patients presented with comorbidities. In‐hospital and 1‐year mortality rates were 4.1% and 14.3%, respectively. Readmissions were common (63% at least once and 37% readmitted ≥2 times). Rates of 1‐year mortality or all‐cause readmission and 1‐year mortality or heart failure readmission were 67% and 34%, respectively, and increased with age, Charlson index, heart failure at admission, and secondary MR etiology; however, the event rate remained notably high in the primary MR subset (64% and 28%, respectively). The mean costs of hospital admissions and of readmissions were 5345±6432 and 10 080±10 847 euros, respectively. Conclusions At the nationwide level, MR was a common reason for admission and affected an elderly population with frequent comorbidities. Less than 10% of patients underwent a valve intervention. All subsets of patients who were conservatively managed incurred high mortality and readmissions rates, and MR represented a major societal burden with an extrapolated annual cost of 350 to 550 million euros (390–615 million US dollars). New strategies to improve the management and outcomes of patients with both primary and secondary MR are critical and warranted.

Clinical studies have demonstrated improved gradients after aortic valve replacement with the Trifecta (TR) valve (Abbott Cardiovascular, St Paul, MN) as compared with the Carpentier-Edwards Magna Ease (ME) valve (Edwards Lifesciences, Irvine, CA). Clinical benefits of this strategy have not been demonstrated.Patients undergoing aortic valve replacement for severe aortic stenosis with either valve were included. Patients were excluded if they underwent concomitant procedures other than coronary artery bypass grafting. Inverse proportion treatment weighting was used in the analysis. The primary outcome was a composite of cardiac mortality, need for reintervention, and freedom from first congestive heart failure (CHF). Secondary outcomes were all-cause mortality, the composite components, and cumulative CHF admission. Follow-up echocardiograms were assessed in a cohort of patients to assess structural valve degeneration.There were 331 patients in the TR group and 360 patients in the ME group. The TR group had more women (48% vs 32%, P.001) with smaller roots (left ventricular outflow tract diameter: TR, 2.11 cm; ME, 2.17 cm; P.001). After weighting there was no significant difference in the composite measure between groups (P.05). There was no difference in all-cause mortality (hazard ratio, 0.82; 95% confidence interval, 0.42-1.59; P = .56), and 5-year survival was 91.9% in the ME group and 93.4% in the TR group. There was no difference in cardiac death, reintervention, or first onset of CHF or incidence of structural valve degeneration between groups. There was no difference in the rate of admissions for CHF per 100 patients between the 2 valve types (P = .19).Early hemodynamic benefits have not translated into differences in medium-term clinical outcomes between these 2 valves. Long-term follow-up is necessary.

ObjectivesUnbiased information regarding the surgical management of patients with mitral regurgitation (MR) at the nationwide level are scarce and mainly US-based. The Programme de Médicalisation des Systèmes d’Information, a mandatory national database, offers the unique opportunity to assess the presentation and outcomes of all consecutive mitral valve (MV) surgeries performed in France in the contemporary era.MethodsWe collected all MV surgeries performed for MR in France in 2014–2016. MR aetiology was classified as degenerative (DMR), secondary (SMR) or Other (rheumatic or congenital disease and infective endocarditis).ResultsDuring the 3-year period, 18 167 MV surgeries were performed in France (55% repair and 45% replacement; 52% isolated). Age was 66±12 years and 59% were male. Aetiology was DMR in 42%, SMR in 16% and other in 42% including 19% with uncertain aetiologies. Overall, in-hospital mortality was 6.5% and increased with age, female gender, Charlson Comorbidity Index, type of surgery (replacement vs repair), associated surgery (combined vs isolated) and MR aetiology (all pConclusionIn this cross-sectional contemporary prospective nationwide database, in-hospital mortality and 1 year rate of death and HF readmission were considerable overall and in all subsets. Repair rates were suboptimal overall especially in the elderly and women subsets. These results underline the need to develop strategies to improve management and outcomes of patients with both DMR and SMR.

Aims There is ongoing controversy about the need for routine transoesophageal echocardiography (TOE) prior to atrial fibrillation (AF) ablation. Recently, the debate was reignited by the publication of a large series of patients showing a prevalence of left atrial appendage thrombus (LAAT) on TOE of 4.4%. We sought to assess the prevalence of LAAT on TOE before AF ablation at our institution. Methods and results Consecutive patients scheduled for AF ablation at our institution between January 2009 and December 2016 were included. All patients were on oral anticoagulation for at least 4 weeks prior to TOE. Transoesophageal echocardiographies were performed 3-5 days prior to scheduled AF ablation. Data were collected utilizing a prospective database. In all, 668 patients and 943 AF ablation procedures were included. Mean age was 64 ± 11 years, 72% were male, average CHADS2 score was 1.0 ± 1.0, and 72% of the patients had paroxysmal AF. At the time of ablation, 496 (53%) were on non-vitamin K antagonist oral anticoagulants (NOACs) and 447 (47%) were on Warfarin. There were three cases with LAAT (3/943, 0.3%), all of whom had persistent AF and were on Warfarin. Two patients underwent surgical ablation and the third patient did not undergo ablation. Conclusion In our experience, the prevalence of LAAT in patients on anticoagulation therapy undergoing TOE before catheter ablation of AF is 0.3%, which was much lower than recently reported. None of the patients with paroxysmal AF or on NOACs were found to have LAAT. Rather than routine use of TOE prior to AF ablation, a risk-based approach should be considered.

Non-invasive approaches to investigate myocardial efficiency can help track the progression of heart failure (HF). This study evaluates the repeatability and reproducibility of 11C-acetate positron emission tomography (PET) imaging of oxidative metabolism. Dynamic 11C-acetate PET scans were performed at baseline and followup (47 ± 22 days apart) in 20 patients with stable HF with reduced ejection fraction. Two observers blinded to patients’ clinical data used FlowQuant® to evaluate test–retest repeatability, as well as intra- and inter-observer reproducibility of 11C-acetate tracer uptake and clearance rates, for the measurement of myocardial oxygen consumption (MVO2), myocardial external efficiency (MEE), work metabolic index (WMI), and myocardial blood flow. Reproducibility and repeatability were evaluated using intra-class-correlation (ICC) and Bland–Altman coefficient-of-repeatability (CR). Test–retest correlations and repeatability were better for MEE and WMI compared to MVO2. All intra- and inter-observer correlations were excellent (ICC = 0.95-0.99) and the reproducibility values (CR = 3%-6%) were significantly lower than the test–retest repeatability values (22%-54%, P

Background Transcatheter aortic valve implantation (TAVI) has become the standard of care for management of high-risk patients with aortic stenosis. Limited data is available regarding the performance of TAVI in patients with native aortic valve regurgitation (NAVR).Methods and Results:We performed a systematic review from 2002 to 2016. The primary outcome was device success as per VARC-2 criteria. Secondary endpoints included procedural complications, and 30-day and 1-year mortality rates. A total of 175 patients were included from 31 studies. Device success was reported in 86.3% of patients - with device failure driven by moderate aortic regurgitation (AR ≥3+) and/or need for a second device. Procedural complications were rare, with no procedural deaths, myocardial infarctions or annular ruptures reported. Procedural safety was acceptable with a low 30-day incidence of stroke (1.5%). The 30-day and 1-year overall mortality rates were 9.6% and 20.0% (cardiovascular death, 3.8% and 10.1%, respectively). Patients receiving 2nd-generation valves demonstrated similar safety profiles with greater device success compared with 1st-generation valves (96.2% vs. 78.4%). This was driven by the higher incidence of second-valve implantation (23.4% vs. 1.7%) and significant paravalvular leak (8.3% vs. 0.0%). Conclusions TAVI demonstrates acceptable safety and efficacy in high-risk patients with severe NAVR. Second-generation valves may afford a similar safety profile with improved device success. Dedicated studies are needed to definitively establish the efficacy of TAVI in this population.

Sex-related differences in aortic valve stenosis previously have been characterized [(1–3)][1], but prior research is limited in patients with low-gradient, low–ejection fraction aortic stenosis (LGAS). The aim of the present TOPAS ([NCT01835028][2]) substudy was to investigate sex-related

The purpose of this paper is to review the current role of echocardiography in the evaluation of patients with low gradient severe aortic stenosis (LG severe AS). Discordant grading of AS severity, in which a small aortic valve area coexists with a small gradient, can result in diagnostic and therapeutic dilemmas. Transthoracic, transesophageal, and stress echocardiography play pivotal roles in reconciling the discordance and clarifying AS severity. Three physiologic categories of LG severe AS can be identified (classical low flow (LF) LG AS, paradoxical LF-LG AS, and normal flow LG AS), each with different prognostic and therapeutic implications. Echocardiographic measures of the severity of the valve stenosis, left ventricular function (and functional reserve), and right heart disease provide important prognostic information to assist with patient management. A systematic comprehensive approach using echocardiography is essential in LG severe AS to understand the reason for the discordant hemodynamics, to confirm AS severity, and to guide therapeutic decision-making.

Valvular heart disease (VHD) is responsible for a major societal and economic burden. Incidence and prevalence of VHD are high and increase as the population ages, creating the next epidemic. In Western countries, the etiology is mostly degenerative or functional disease and strikes an elderly population with multiple comorbidities. Epidemiological studies have shown that VHD is commonly underdiagnosed, leading to patients presenting late in their disease course, to an excess risk of mortality and morbidity and to a missed opportunity for intervention. Once diagnosed, VHD is often undertreated with patients unduly denied intervention, the only available curative treatment. This gap between current recommendations and clinical practice and the marked under-treatment is at least partially related to poor knowledge of current National and International Societies Guidelines. Development of a valvular heart team involving multidisciplinary valve specialists including clinicians, imaging specialists, interventional cardiologists and surgeons is expected to fill these gaps and to offer an integrated care addressing all issues of patient management from evaluation, risk-assessment, decision-making and performance of state-of-the-art surgical and transcatheter interventions. The valvular heart team will select the right treatment for the right patient, improving cost-effectiveness and ultimately patients’ outcomes.

Background Aortic valve replacement (AVR) is recommended for patients with low-flow, low-gradient (LFLG) and true-severe aortic stenosis (TSAS). However, there is very few data on the potential benefit of AVR in patients with LFLG pseudo-severe (i.e. moderate) AS (PSAS). Methods Consecutive patients with aortic valve area ≤0.6 cm2/m2, mean gradient 1200 AU in women and >2000 AU in men). To account for between-treatment-group differences, inverse probability-of-treatment weighting was combined to Cox proportional hazards regression. Results Among the 430 patients included in this study, 297 (69%) were classified as TSAS and 274 (57%) underwent AVR. Of note, 21% of the patients treated by AVR were classified as PSAS. In patients managed conservatively (ConsRx), 52% had PSAS and 48% TSAS. During a median follow-up of 28 months [8–60], 198 patients died. The adjusted weighted hazard ratio (awHR) of death associated with AVR as compared to ConsRx was 0.42 [0.24–0.73] (p Figure 1 Conclusion The results of this study suggest that AVR is associated with a survival benefit not only in LFLG patients with TSAS but also in those with PSAS. Randomized trials are needed to confirm the benefit of AVR in patients with moderate AS and depressed LV systolic function. Acknowledgement/Funding Canadian Institute of Health Research

Background B-type natriuretic peptide (BNP) and aminoterminal-proBNP (NT-proBNP) are well established surrogates of LV function impairment. However, data are scarce regarding their prognostic value to risk-stratify patients with classical low-flow, low-gradient aortic stenosis (LFLG-AS, with low left ventricular [LV] ejection fraction). Methods The TOPAS study is a prospective observational cohort of 240 patients with aortic valve area Results BNP significantly predicted one-year (area under the receiver operating-characteristic curve [AUC]) 0.62±0.04, p=0.026) but not three-year mortality. After adjustment for the severity of AS, initial treatment (aortic valve replacement [AVR] vs. conservative management [ConsRx]), age, sex and the EuroSCORE (Model#1), BNP-ratio>550 pg/ml had a trend to predict time to death (HR=2.14 [1.00–4.58], p=0.05). In contrast, NT-proBNP ratio significantly predicted both one and three-year mortality (AUC=0.67±0.04 and 0.66±0.05, both p=0.001), and independently predicted time to death (HR=1.39 per 1 unit of Log transformed NT-proBNP [1.11–1.74], p=0.004). In a head-to-head comparison (108 patients with both biomarkers), the AUCs to predict one and thre-year mortality were significantly higher with NT-proBNP versus BNP (p1700, aHR=0.11 [0.01–0.83], p=0.033). The survival benefit associated with AVR interacted with NT-proBNP (p Survival according to NT-proBNP and AVR Conclusion NT-proBNP appears to be an excellent biomarker for the clinical purpose of risk-stratifying classical LFLG-AS. A threshold of 1700 pg/ml i.e. close to the diagnostic threshold for heart failure in acute dyspnea, was a strong independent determinant of the survival benefit associated with aortic valve replacement. Our findings suggest that NT-proBNP should be preferred over BNP. Acknowledgement/Funding Canadian Institute of Health Research

Alterations in atrial metabolism may play a role in the perpetuation of atrial fibrillation (AF). This study sought to compareSeventy-two patients who underwent myocardial viability assessment were evaluated. AF patients (36) had persistent or permanent AF based on history and ECG. Patients without AF (36) were matched to AF patients based on sex, diabetes, age, and LVEF. Maximum and mean FDG Standard Uptake Values (SUV) in the left atrial (LA) wall and right atrial (RA) wall were measured. Tissue-to-blood ratios (TBR) were calculated as atrial wall to blood-pool activity. Atrial volumes were measured by echocardiography.Maximum and mean FDG SUV and TBRs were significantly increased in the RA (but not the LA) of patients with AF compared to those without (P0.01). When accounting for changes in atrial volume, the presence of AF remained a significant predictor of higher RAIn patients with LV dysfunction from ischemic cardiomyopathy, LA and RA glucose metabolism are differentially altered in those with persistent atrial fibrillation. Further investigations should elucidate the temporal relationship between AF and glucose metabolic changes, as a potential target for therapy.Las alteraciones en el metabolismo auricular pueden desempeñar un papel en la persistencia de lafibrilación auricular (FA). Este estudio buscó comparar la captación del PET con 18F fluorodesoxiglucosa(FDG), en pacientes con disfunción del VI con y sin FA. MéTODOS: Se evaluaron setenta y dos pacientes que se sometieron a evaluación de viabilidad miocárdica. Los pacientes con fibrilación auricular (36) tenían fibrilación auricular persistente o permanente según su historia clínica y el ECG. Los pacientes sin FA (36) se compararon con los pacientes con FA en base a género, diabetes, edad y FEVI. Se midieron los valores de captación estándar (SUV) máximos y medios de FDG en la pared de la aurícula izquierda (LA) y la pared de la aurícula derecha (RA), y se calcularon las relaciones de tejido al pool sanguíneo (TBR) como pared-a-pool sanguíneo. Volúmenes auriculares fueron medidos por ecocardiografía RESULTADOS: Los SUV y TBR de FDG máximos y medios se encontraron significativamentemayores en la RA(pero no en la LA) de los pacientes con FA en comparación con los que no la tenían (p0.01). Al tener en cuenta los cambios en el volumen auricular, la presencia de FA siguió siendo un predictor significativo de una mayor captación de FDG en RA背景: 心房代谢的改变可能在心房颤动 (AF) 的持续中起作用。本研究旨在比较有无合并房颤 左心室 (LV) 功能障碍患者中, 18F-氟脱氧葡萄糖 (FDG) 在PET 中的摄取量有无差异。 研究方法: 本研究纳入了72 名接受心肌活力评估的患者。根据病史和心电图, 房颤患者 (36 人) 诊 断为持续性或永久性房颤。根据性别、糖尿病、年龄和LVEF, 对应匹配无房颤患者36 人。 本研究测量了左心房 (LA) 壁和右心房 (RA) 壁的最大和平均FDG 标准摄取值 (SUV), 并计算了组织-血液比率 (TBR), 即心脏壁-血液池。心房容积由超声心动图测量。 结果: 与无房颤患者相比, 房颤患者的RA (但不包括LA) 的最大和平均FDG 标准摄取值 (SUV) 和组织-血液比率 (TBRs) 都明显增加 (P0.01)。当考虑到心房容积的变化时, 患者是 否合并房颤仍然是右房最大标准化摄取值 (RALes changements du métabolisme auriculaire peuvent jouer un rôle dans la perpétuation de la fibrillation auriculaire (FA). La présente étude avait pour but de comparer la captation du 18F-fluorodeoxyglucose (FDG) en TEP ( tomographie par émission de positrons) chez les patients avec une dysfonction du VG avec FA versus sans FA. MéTHODOLOGIE: Soixante-douze patients chez qui une étude de viabilité myocardique a été effectuée ont été évalués. Les patients avec FA (36) avaient une FA persistante ou permanente basée sur l’histoire clinique et l’ECG. Les patients sans FA (36) ont été assortis aux patients avec FA selon leur sexe, diabete, leur age et FEVG. Les ICN (indice de captation normalisée) du FDG maximal et moyen au niveau des parois de l’oreillette gauche (OG) et de l’oreillette droite (OD) ont été mesurées et les rapport tissus-sang (RTS) ont été calculés comme parois-pool sanguin. Les volumes auriculaires ont été mesurés par échocardiographie. RéSULTATS: Les ICN maximaux et moyens du FDG et les RTS étaient significativement augmentés dans OD (mais pas dans OG) chez les patients avec FA comparativement à ceux qui n’ont pas de FA (p0.01). Lorsque les changements du volume auriculaire sont pris en considération, la présence avec FA demeure un facteur prédicteur significatif d’une captation du FDG OD maximale plus élevée mais pas pour la captation OD moyenne.Chez les patients avec dysfonction du VG reliée à une cardiomyopathie ischémique, le métabolisme du glucose dans OG et OD est altéré différemment chez les patients avec une FA persistante. D’autres études devront être effectuées afin d’élucider la relation temporelle entre la FA et les changements du métabolisme du glucose comme cible potentielle pour la thérapie.

Cardiac sympathetic nervous system (SNS) dysfunction is associated with poor prognosis in chronic heart failure patients. This study characterized the reproducibility and repeatability of [Dynamic HED PET-CT scans were performed 47 ± 22 days apart in 20 patients with stable heart failure and reduced ejection fraction. Three observers, blinded to clinical data, used FlowQuant® to evaluate the test-retest repeatability and inter- and intra-observer reproducibility of HED tracer uptake and clearance rates to measure global (LV-mean) retention index (RI), volume of distribution (VIntra- and inter-observer correlations of both VQuantitative measures of global and regional SNS innervation were most repeatable using the simple RI method of analysis compared with the more complex V

Reduced left ventricular (LV) function is associated with increased myocardial oxygen consumption rate (MVO2) and altered sympathetic activity, the role of which is not well described in right ventricular (RV) dysfunction. 33 patients with left heart failure were assessed for RV function/size using echocardiography. Positron emission tomography (PET) was used to measure 11C-acetate clearance rate (kmono), 11C-hydroxyephedrine (11C-HED) standardized uptake value (SUV), and retention rate. RV MVO2 was estimated from kmono. 11C-HED SUV and retention indicated sympathetic neuronal function. A composite clinical endpoint was defined as unplanned cardiac hospitalization within 5 years. Patients with (n = 10) or without (n = 23) RV dysfunction were comparable in terms of sex (male: 70.0 vs 69.5%), LV ejection fraction (39.6 ± 9.0 vs 38.6 ± 9.4%), and systemic hypertension (70.0 vs 78.3%). RV dysfunction patients were older (70.9 ± 13.5 vs 59.4 ± 11.5 years; P = .03) and had a higher prevalence of pulmonary hypertension (60.0% vs 13.0%; P = .01). RV dysfunction was associated with increased RV MVO2 (.106 ± .042 vs .068 ± .031 mL/min/g; P = .02) and decreased 11C-HED SUV and retention (6.05 ± .53 vs 7.40 ± 1.39 g/mL (P

Up to 1/3 of patients with both reduced or preserved left ventricular ejection fraction (LVEF), harbor a mean pressure gradient (MPG) 30–40 mm Hg at peak while AVA remains 1250 AU in women and >2000 UA in men strongly suggest severe AS. Combination of dobutamine echocardiography and AVC scoring enables assessment of AS severity with high confidence. The subset of patients with discordant grading and preserved LVEF is heterogenous and encompasses various conditions. A minority harbor a low flow state related to a reduced myocardial performance, an increased arterial afterload or combination of both. A low flow state is an important prognostic factor but does not provide any information regarding AS severity. Similarly to patients with reduced LVEF, assessment of the degree of AVC seems the best method to differentiate patients with pseudo-severe AS from patients with true severe AS. The latter should be referred for an intervention if symptomatic whereas the optimal management of the former subset remains uncertain.

Background: Cardiotoxicity from anthracycline-based chemotherapy is an important cause of early and late morbidity and mortality in breast cancer patients. Left ventricular (LV) function is assessed for patients receiving anthracycline-based chemotherapy to identify cardiotoxicity. However, animal studies suggest that right ventricular (RV) function may be a more sensitive measure to detect LV dysfunction. The purpose of this pilot study was to determine if breast cancer patients undergoing anthracycline-based chemotherapy experience RV dysfunction. Methods: Forty-nine breast cancer patients undergoing anthracycline-based chemotherapy at the Ottawa Hospital between November 2007 and March 2013 and who had 2 echocardiograms performed at least 3 months apart were retrospectively identified. Right atrial area (RAA), right ventricular fractional area change (RV FAC) and RV longitudinal strain of the free wall (RV LSFW) were evaluated according to the American Society of Echocardiography guidelines. Results: The majority (48/49) of patients were females with an average age of 53.4 (95% CI: 50.1-56.7 years). From baseline to follow-up study, average LV ejection fraction (LVEF) decreased from 62.22 (95% CI: 59.1-65.4) to 57.4% (95% CI: 54.0-60.9) (P = 0.04). During the same time period, the mean RAA increased from 12.1 cm2 (95% CI: 11.1-13.0 cm2) to 13.8 cm2 (95% CI: 12.7-14.9 cm2) (P = 0.02), mean RV FAC decreased (P = 0.01) from 48.3% (95% CI: 44.8-51.74) to 42.1% (95% CI: 38.5-45.6%), and mean RV LSFW worsened from -16.2% (95% CI: -18.1 to -14.4%) to -13.81% (95% CI: -15.1 to -12.5%) (P = 0.04). Conclusion: This study demonstrates that breast cancer patients receiving anthracycline-based chemotherapy experience adverse effects on both right atrial size and RV function. Further studies are required to determine the impact of these adverse effects on right heart function and whether this represents an earlier marker of cardiotoxicity.