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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 <1 cm(2)), low ejection fraction (EF) (Results: 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. Conclusions: 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. [ABSTRACT FROM AUTHOR]

Objectives: This study was undertaken to analyse outcomes of aortic valve repair using additional material and compare the results to those of cusp repair without the use of the pericardial patch., Methods: All consecutive patients aged over 16 who underwent aortic valve repair with external ring annuloplasty for isolated aortic insufficiency, aortic insufficiency and tubular aortic aneurysm or aortic root aneurysm between May 2003 and November 2019 were included in a cohort study. Data were collected and analysed from the AVIATOR registry (AorticValve repair InternATiOnal Registry). Propensity score framework analysis (inverse probability of treatment weighting) was used to compare outcomes of the groups while controlling for confounders., Results: During the 16-year study period, 618 patients underwent aortic valve repair. Eight-year survival rate was 92% in the patch group and 90.2% in the no patch group without significant differences [P = 0.957 inverse probability of treatment weighting (IPTW) weighted]. Early valve-related reoperation was more frequent in the patch group as compared to the no patch group (6% vs 1%, P < 0.001 IPTW weighted), the freedom from aortic valve-related reintervention and from structural valve deterioration at 8 years was not significantly different between the patch and no patch groups (93.7% vs 94%, P = 0.968 IPTW weighted; and 99.3% vs 96.7%, P = 0.964 IPTW weighted)., Conclusions: Although a higher rate of early reintervention was observed, aortic valve repair using the pericardial patch, in a standardized approach using external annuloplasty, with effective coaptation height of at least 9 mm, was not associated with an increase in mid-term aortic valve-related reoperation or structural valve deterioration as compared to valve repair without the pericardial patch., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Despite growing evidence that aortic valve repair improves long-term patient outcomes and quality of life, aortic valves are mostly replaced. We evaluate the effect of aortic valve repair versus replacement in patients with dystrophic aortic root aneurysm up to 4 years., Methods: The multicentric CAVIAAR (Conservation Aortique Valvulaire dans les Insuffisances Aortiques et les Anévrismes de la Racine aortique) prospective cohort study enrolled 261 patients: 130 underwent standardized aortic valve repair (REPAIR) consisting of remodelling root repair with expansible aortic ring annuloplasty, and 131 received mechanical composite valve and graft replacement (REPLACE). Primary outcome was a composite criterion of mortality, reoperation, thromboembolic or major bleeding events, endocarditis or operating site infections, pacemaker implantation and heart failure, analysed with propensity score-weighted Cox model analysis. Secondary outcomes included major adverse valve-related events and components of primary outcome., Results: The mean age was 56.1 years, and valve was bicuspid in 115 patients (44.7%). Up to 4 years, REPAIR did not significantly differ from REPLACE in terms of primary outcome [Hazard Ratio (HR) 0.66 (0.39; 1.12)] but showed significantly less valve-related deaths (HR 0.09 [0.02; 0.34]) and major bleeding events (HR 0.37 [0.16; 0.85]) without an increased risk of valve-related reoperation (HR 2.10 [0.64; 6.96]). When accounting for the occurrence of multiple events in a single patient, the REPAIR group had half the occurrence of major adverse valve-related events (HR 0.51 [0.31; 0.86])., Conclusions: Although the primary outcome did not significantly differ between the REPAIR and REPLACE groups, the trend is in favour of REPAIR by a significant reduction of valve-related deaths and major bleeding events. Long-term follow-up beyond 4 years is needed to confirm these findings., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: We investigated whether aortic valve fenestrations (respected or fixed) represent a factor associated with recurrent aortic insufficiency or reoperation after repair., Methods: Between 2003 and 2019, patients who underwent aortic valve repair were included. Aortic insufficiency phenotypes were root aneurysm (repair: root remodelling + annuloplasty), ascending aorta aneurysm (repair: tubular aortic replacement + annuloplasty) and isolated regurgitation (repair: single/double annuloplasty). Fenestrations were either respected or fixed according to their features., Results: A total of 618 patients (out of 798 operated on; 77.4%) had their valve repaired, with 167 cases of fenestrations (128 were respected, 39 fixed-32 with a patch, 6 with running suture and 1 with both). After conducting propensity score matching between no-fenestration (n = 167) and fenestration groups (n = 167), respectively, we noted the following: survival [90.3% (n = 7 deaths) vs 95.8% (n = 4)], cumulative incidence of reoperation [6.7% (n = 7) vs 5.2% (n = 4)], aortic insufficiency grade ≥ 3 [6.4% (n = 6) vs 4.4% (n = 4)] and grade ≥ 2 [28.9% (n = 28) vs 37.1% (n = 35)] were similar at 9 years [P = 0.94; median follow-up: 2.2, interquartile range: (0.8, 5.8)], whether fenestration was respected (P = 0.55) or fixed (P = 0.6, at 6 years). Standardization of the surgical approach (consisting of double annuloplasty in isolated regurgitation phenotype and expansible subvalvular annuloplasty with effective height assessment with remodelling repair for root aneurysm phenotype) reduced the risk of reoperation (era before standardization: hazard ratio: 5.4, 95% confidence interval: 1.9-15.7, P = 0.002)., Conclusions: Fenestration, respected or fixed, is not a factor associated with reoperation or recurrence of significant aortic insufficiency after valve repair if the surgical approach is standardized., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To determine the 4D Flow Cardiac Magnetic Resonance (CMR) thresholds that achieve the best agreement with transthoracic echocardiography (TTE) for grading mitral regurgitation (MR)., Methods: We conducted a single-center prospective study of patients evaluated for chronic primary MR in 2016-2020. MR was evaluated blindly by TTE and 4D Flow CMR, respectively by two cardiologists and two radiologists with decades of experience. MR was graded with both methods as mild, moderate, or severe. 4D Flow CMR measurements included MR regurgitant volume per beat (RV) and mitral anterograde flow per beat (MF). RF was obtained as the ratio RV/MF. Additionally, MF was compared to left ventricular stroke volume (LVSV) by cine-CMR., Results: We included 33 patients in the initial cohort and 33 in the validation cohort. Inter-observer agreement was excellent for 4D Flow CMR ICC = .94 (95% CI, .86-.97, p < 0.0001). Using recommended TTE thresholds (30 ml, 60 ml, 30%, 50%), agreement was moderate for RV and RF. The best agreement between 4D Flow CMR and TTE was obtained with CMR thresholds of 20 and 40 ml for RV (κ = .93; 95% CI, .8-1) and 20% and 37% for RF (κ = .90; 95% CI, .7-.9). In the validation cohort, agreement between TTE and 4D Flow CMR was good with the optimal thresholds (κ = .78; 95% CI, .61-.94)., Conclusion: We propose CMR thresholds that provide a good agreement between TTE and CMR for grading MR. Further studies are needed to fully validate 4D-Flow CMR accuracy for primary MR quantification., (© 2022 Wiley Periodicals LLC.)

Background: There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS)., Objectives: This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey., Methods: Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention., Results: A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age-adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001)., Conclusions: A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians., Competing Interests: Funding Support and Author Disclosures Since the start of EORP, the following companies have supported the program: Abbott Vascular Inc (2011-2021), Amgen Cardiovascular (2009-2018), AstraZeneca (2014-2021), Bayer AG (2009-2018), Boehringer Ingelheim (2009-2019), Boston Scientific (2009-2012), Bristol Myers Squibb–Pfizer Alliance (2011-2019), Daiichi-Sankyo Europe GmbH (2011-2020), Alliance Daiichi-Sankyo Europe GmbH and Eli Lilly and Company (2014-2017), Edwards (2016-2019), Gedeon Richter Plc (2014-2016), Menarini International Operations (2009-2012), MSD-Merck and Co (2011-2014), Novartis Pharma AG (2014-2020), ResMed (2014-2016), Sanofi (2009-2011), Servier (2009-2018), and Vifor (2019-2022). Dr Prendergast has received grants and personal fees from Edwards Lifesciences; has received personal fees from Abbott and Anteris outside the submitted work. Dr Wendler has received personal fees from Edwards Lifesciences and Neovasc during the conduct of the study. Dr Bax has received grants from Abbott, Edwards Lifesciences, Medtronic, Boston Scientific, Biotronik, GE Healthcare, and Bayer; and has received personal fees from Abbott during the conduct of the study. Dr Vahanian has received personal fees from Edwards Lifesciences, Medtronic, and Abbott Vascular during the conduct of the study; and has received personal fees from Edwards Lifesciences, Medtronic, Abbott Vascular, and Cardiovalve outside the submitted work. Dr Iung has received personal fees from Edwards Lifesciences; and has received travel fees from Boehringer Ingelheim outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Standardization of aortic valve repair techniques with use of a calibrated annuloplasty have led to improved long-term outcomes in dystrophic aortic insufficiency. It can also improve dissemination of techniques and rates of aortic valve repair. Dystrophic aortic insufficiency can be found in three aortic phenotypes: dilated aortic root, dilated ascending aorta and isolated aortic insufficiency. The aortic annulus is invariably dilated above 25 mm in the vast majority of cases of aortic insufficiency, regardless of whether the aorta is dilated or not. A dilated annulus is a risk factor for late failure of aortic valve repair if not addressed at the time of surgery. We perform a calibrated annuloplasty at both sub- and supra-valvular levels in order to restore the ratio of sinotubular junction and annulus. Current evidence shows aortic valve repair reduces valve-related mortality compared to prosthetic valve replacement, with an improved quality of life.

Aims: Cardiac fibrosis is associated with left ventricular (LV) remodelling and contractile dysfunction in aortic stenosis (AS). The fibrotic process in this condition is still unclear. The aim of this study was to determine the role of both local and systemic inflammation as underlying mechanisms of LV fibrosis and contractile dysfunction. The diagnostic values of 2D-strain echocardiography and serum biomarkers in the evaluation of cardiac fibrosis in this condition were assessed through correlation analyses., Methods and Results: Patients with AS referred for surgical valve replacement were prospectively and consecutively included. They all had a comprehensive echocardiography including 2D strain. Blood samples were collected to measure cytokines and inflammatory biomarkers using Luminex bead-based assays. A per-surgical myocardial biopsy of the basal antero-septal segment (S1) was performed. Serial sections of each biopsy were stained with Sirius red. Digital image analysis was used to quantify fibrosis. Immunostainings using specific antibodies against macrophage, glycoprotein (gp) 130, and interleukin 6 (IL-6) were also performed. Patients were divided into tertiles reflecting the severity of fibrosis: mild, moderate, and severe load (TF1 to TF3). The mean age of the 58 included patients was 73 ± 11 years. Twenty-four (43%) were in New York Heart Association III-IV. Mean aortic valve area was 0.8 ± 0.2 cm 2 . Mean aortic stenosis peak velocity and mean gradient were respectively 4.5 ± 0.8 m/s and 54 ± 15 mmHg. The mean LV ejection fraction was 54 ± 12%, and the global LV longitudinal strain was -15 ± 4%. The mean S1 strain, corresponding to the biopsied region, was -10 ± 6% and was strongly correlated to fibrosis load (R = 0.83, P < 0.0001). TF3 was associated with higher mortality (P = 0.009), higher serum C-reactive protein and IL-6, and lower gp130 compared with the other tertiles (P < 0.05). IL-6 and gp130 were expressed in the heart and respectively in the plasma membrane of macrophages and in the cytoplasm of both macrophages and cardiomyocytes. During follow-up, three patients died and were all in the third fibrosis tertile., Conclusions: We found a positive correlation between elevated inflammatory markers and degree of fibrosis load. These two parameters were associated with worse outcomes in patients with severe AS. Our results may be of interest especially in patients for whom a transcatheter aortic valve implantation is indicated and myocardial biopsy is not possible. Strategies aiming at preventing inflammation might be considered to decrease or limit the progression of cardiac fibrosis in patients followed for AS., (© 2019 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Aortic valve (AV) repair is the preferred surgical treatment in young patients with aortic regurgitation (AR) and/or proximal aorta aneurysm, as noted in the recent European Society of Cardiology (ESC) guidelines. However, this surgical option is still underused in clinical practice. This emphasizes the need to build a heart team dedicated to AV repair with expert surgeons and echocardiographers. Surgical techniques are now standardized in their approaches to enhance the reproducibility and expansion of AV repair. The objective of this keynote is to also demonstrate the need for a standardized pre-pump intra-operative echocardiography protocol to fulfill surgeon's needs in providing a road map and predicting techniques to be used for an effective and durable repair., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Concerns have been previously raised regarding the potential early degeneration of the Mitroflow (Sorin Group Italia, Saluggia, Vercelli, Italy) bioprostheses. We aimed to evaluate our clinical experience with the Mitroflow LXA prosthesis for aortic valve replacement., Methods: We prospectively analyzed data from 227 consecutive patients (133 males, mean age 73.9±9.2 years) implanted with the Mitroflow LXA between February 2007 and October 2011. Follow-up data were obtained by contacting the referring cardiologists. Kaplan-Meier curves were constructed for all-cause mortality, valve related mortality and structural valve degeneration (SVD). Multivariable analysis was conducted to identify SVD predictors., Results: Median follow-up time was 54.2±37.9 months and completeness of follow-up was 95%. Overall mortality in the entire series was at 31% (N.=71) and mortality from cardiac or unknown causes at 20% (N.=46). SVD occurred in 24 patients (10%) (median delay between implantation and diagnosis: 62.6 (36.5) months). Reintervention was required in 20 cases (13 redo surgery, 7 percutaneous transcatheter valve intervention). The 8 years actuarial global survival was 54.7±4.9%, freedom from valve related mortality 67.5±4.9% and freedom from SVD 72±8%. The estimated freedom from SVD was significantly (P=0.007) longer in larger prosthesis (diameter >21 mm, 77±11%) compared to the smaller devices (≤21 mm, 59±13%.). Multivariate analysis identified smaller prostheses and age at implantation as independent predictors of SVD., Conclusions: The Mitroflow LXA showed evidence of early SVD in this cohort. A close follow-up of these patients is strongly advised.

Background: Aortic stenosis (AS) and transthyretin cardiac amyloidosis (TTR-CA) are both frequent in elderly. The combination of these two diseases has never been investigated., Aims: To describe patients with concomitant AS and TTR-CA., Methods: Six cardiologic French centres identified retrospectively cases of patients with severe or moderate AS associated with TTR-CA hospitalized during the last 6 years., Results: Sixteen patients were included. Mean ± SD age was 79 ± 6 years, 81% were men. Sixty per cent were NYHA III-IV, 31% had carpal tunnel syndrome, and 56% had atrial fibrillation. Median (Q1;Q4) NT-proBNP was 4382 (2425;4730) pg/mL and 91% had elevated cardiac troponin level. Eighty-eight per cent had severe AS (n = 14/16), of whom 86% (n = 12) had low-gradient AS. Mean ± SD interventricular septum thickness was 18 ± 4 mm. Mean left ventricular ejection fraction and global LS were 50 ± 13% and -7 ± 4%, respectively. Diagnosis of TTR-CA was histologically proven in 38%, and was based on strong cardiac uptake of the tracer at biphosphonate scintigraphy in the rest. Eighty-one per cent had wild-type TTR-CA (n = 13), one had mutated Val122I and 19% did not had genetic test (n = 3). Valve replacement was surgical in 63% and via transcatheter in 13%. Median follow-up in survivors was 33 (16;65) months. Mortality was of 44% (n = 7) during the whole follow-up period., Conclusions: Combination of AS and TTR-CA may occur in elderly patients particularly those with a low-flow low-gradient AS pattern and carries bad prognosis. Diagnosis of TTR-CA in AS is relevant to discuss specific treatment and management., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Aims: To evaluate the prognostic impact of QRS width in patients with low-flow/low-gradient aortic stenosis (LF/LGAS)., Methods and Results: Among 88 consecutive patients referred to our institution for LF/LGAS from September 1994 to March 2007, baseline demographic, clinical, echocardiographic, and electrocardiographic data were collected. This population was divided into two groups according to baseline QRS duration (cut-off QRS ≥130 ms). Follow-up data, including electrocardiographic evolution and overall mortality, were analysed. The mean follow-up duration was 3.1 (2.2-6.2) years. In the whole group, 67 patients underwent surgical aortic valve replacement. Forty-nine patients (56%) had a QRS duration ≥130 ms. Among operated patients, there was no significant change in QRS duration between baseline and latest follow-up (126 ± 26 ms vs. 131 ± 25 ms; P = 0.82). In addition, wider QRS was a strong independent predictor of overall mortality (hazard ratio 2.20, 95% confidence interval 1.15-4.24; P = 0.027)., Conclusion: Significant intraventricular conduction disturbances are common in patients with LF/LGAS and do not recover after aortic valve replacement. QRS duration is strongly associated with mortality in this selected population., (© 2014 The Authors. European Journal of Heart Failure © 2014 European Society of Cardiology.)

Background: Global longitudinal strain (GLS) and basal longitudinal strain (BLS) assessed using two-dimensional speckle-tracking imaging have been proposed as subtle markers of left ventricular (LV) systolic dysfunction with potential prognostic value in patients with aortic stenosis (AS). The aim of this study was to evaluate the relationship between longitudinal strain and symptomatic status in patients with AS., Methods: GLS and BLS were measured in 171 patients with pure, isolated, at least mild AS prospectively enrolled at two institutions. The population was divided into four groups: asymptomatic nonsevere AS (n = 55), asymptomatic severe AS with preserved LV ejection fraction (LVEF; ≥50%) (n = 37), symptomatic severe AS with preserved LVEF (n = 60), and severe AS with reduced LVEF (<50%) (n = 19)., Results: GLS was significantly different among the four groups (P < .0001), but the difference was due mainly to patients with reduced LVEFs. In addition, there was an important overlap among the groups, and in multivariate analysis, after adjustment for age, gender, AS severity, and LVEF, GLS was not an independent predictor of symptomatic status (P = .07). BLS was also significantly different among the four groups (P < .0001) but in contrast was independently associated with symptomatic status (P < .0001). However, as for GLS, there was an important overlap between groups and differences were close to intraobserver or interobserver variability (1.3 ± 1.1% and 2.0 ± 1.6%, respectively)., Conclusions: In this prospective multicenter cohort of patients with wide ranges of AS severity, symptoms, and LVEFs, BLS but not GLS was independently associated with symptomatic status. However, there was an important overlap among groups, and differences were close to measurements' reproducibility, raising caution regarding the use of longitudinal strain, at least as a single criterion, in the decision-making process for patients with severe asymptomatic AS., (Copyright © 2013. Published by Mosby, Inc.)

Background: Right ventricular (RV) function is a strong predictor of patient outcome after cardiac surgery. Limited studies have compared the predictive value of RV global longitudinal strain (RV-GLS) with tricuspid annular plane systolic excursion (TAPSE) and RV fractional area change (RVFAC) in this setting., Methods: The study included 250 patients (66 ± 13 years old, LVEF = 52% ± 12%) referred for cardiac surgery (EuroSCORE-II = 4.8% ± 8.0%). RV function before surgery was assessed by RV-GLS by using speckle-tracking analysis (3-segment from the RV free wall), RVFAC and TAPSE was compared with postoperative outcome defined by 1-month mortality., Results: Overall, 19 patients (7.6%) had RVFAC < 35%, 34 (13.6%) had TAPSE < 16 mm, and 99 (39.6%) had impaired RV-GLS > -21% (35% with normal RVFAC ≥ 35%). Postoperative death (n = 25) was higher in patients with abnormal RV-GLS > -21% (22% vs 3%; P < .0001), TAPSE < 16 mm (24% vs 8%; P = .007), and RVFAC < 35% (32% vs 9%; P = .001). Mortality was 3% in patients with preserved RV-GLS. In patients with preserved RVFAC ≥ 35% but abnormal RV-GLS, mortality was similar to that of those with RVFAC < 35% (20% vs 32%; P = .12). Among RV systolic indexes, only RV-GLS was associated with patient outcome by multivariate analysis adjusted to EuroSCORE-II and cardiopulmonary bypass duration., Conclusions: RV-GLS is a sensitive marker of RV dysfunction and correlates with postoperative mortality., (Copyright © 2013 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

Transcatheter aortic valve implantation (TAVI) is effective in treating severe aortic stenosis in high-risk surgical patients. We evaluated the value of the QRS duration (QRSd) in predicting the mid-term morbidity and mortality after TAVI. We conducted a prospective cohort study of 91 consecutive patients who underwent TAVI using the CoreValve at our teaching hospital cardiology unit in 2008 to 2010 who survived to hospital discharge; 57% were women, and their mean age was 84 ± 7 years. The QRSd at discharge was used to classify the patients into 3 groups: QRSd ≤120 ms, n = 18 (20%); QRSd >120 ms but ≤150 ms, n = 30 (33%); and QRSd >150 ms, n = 43 (47%). We used 2 end points: (1) all-cause mortality and (2) all-cause mortality or admission for heart failure. After a median of 12 months, the normal-QRSd patients showed a trend toward, or had, significantly better overall survival and survival free of admission for heart failure compared with the intermediate-QRSd group (p = 0.084 and p = 0.002, respectively) and the long-QRSd group (p = 0.015 and p = 0.001, respectively). The factors significantly associated with all-cause mortality were the Society of Thoracic Surgeons score, aortic valve area, post-TAVI dilation, acute kidney injury, hospital days after TAVI, and QRSd at discharge. On multivariate analysis, QRSd was the strongest independent predictor of all-cause mortality (hazard ratio 1.036, 95% confidence interval 1.016 to 1.056; p <0.001) and all-cause mortality or heart failure admission (hazard ratio 1.025, 95% confidence interval 1.011 to 1.039; p <0.001). The other independent predictors were the Society of Thoracic Surgeons score, acute kidney injury, and post-TAVI hospital days. In conclusion, a longer QRSd after TAVI was associated with greater morbidity and mortality after 12 months. The QRSd at discharge independently predicted mortality and morbidity after TAVI., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Decrease in blood platelet count has been described after percutaneous coronary intervention and surgical valve replacement, although no study has been performed in the setting of transcatheter aortic valve implantation (TAVI). The aim of this study was to address the incidence, mechanism, and impact of blood platelet count decrease after TAVI. One hundred forty-four consecutive patients (mean age 84 ± 7 years, 64 men) with severe symptomatic aortic stenosis who underwent TAVI from December 2007 to July 2011 were enrolled. Blood platelet count was recorded before and after aortic valve implantation. Decrease in blood platelet count was compared with in-hospital major adverse cardiovascular events (death, stroke, and major or life-threatening bleeding). Blood platelet count decreases occurred in all but 1 patient. The percentage of platelet count decrease averaged 34 ± 15% and was 24% greater than blood protein decrease. Decrease in platelet count was associated with a higher rate of prosthesis migration, longer x-ray and procedural times, and larger contrast amounts (230 ± 128 ml for the third tertile vs 170 ± 77 ml for the second and first tertiles, p = 0.0006), but no association was observed with regard to changes in bilirubin. In-hospital major adverse cardiovascular events (n = 50 [35%]) were observed more frequently in patients with severe platelet count decreases (21% for the first tertile, 35% for the second tertile, and 48% for the third tertile, p = 0.02). Finally, the percentage of blood platelet count decrease was the only predictor of in-hospital major adverse cardiovascular events (odds ratio 1.67, 95% confidence interval 1.05 to 2.67, p = 0.03). In conclusion, a decrease in platelet count is a common phenomenon after TAVI, and its severity is associated with poor outcomes., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To identify clinical and electrical factors predicting delayed high-degree atrio-ventricular block (AVB) after transcatheter aortic valve implantation (TAVI)., Background: TAVI is a new technique for treating severe aortic valve stenosis in patients at high surgical risk but can be followed by high-grade AVB requiring permanent pacing (PP)., Methods and Results: The study included 79 patients (82 ± 17 years, Euroscore = 23% ± 10%) free of PP need before and immediately after TAVI procedure. Delayed high-degree AVB was defined by types 2 or 3 AVB diagnosed at least 24 hr after the index procedure. Permanent pacemaker implantation was performed for all these patients. We compared clinical and electrical variables before and after TAVI in patients with delayed AVB or not. TAVI was performed successfully in all patients. The 21 (26%) patients who exhibited delayed high-grade AVB had significantly deeper prosthesis implantation (12 ± 4 mm vs. 9 ± 5 mm, P = 0.03) and wider post-TAVI QRS duration (155 ± 17 msec vs. 131 ± 25 msec, P = 0.0004), with no difference in baseline QRS duration. Post-TAVI QRS duration was the only independent predictor of post-TAVI permanent for delayed high-degree AVB (P = 0.02). After a mean follow-up of 10 ± 8 months, all 21 patients with post-TAVI QRS ≤ 128 msec were free of high-grade AVB, whereas 21/55 (38%) patients with post-TAVI QRS >128 msec had PP (P = 0.0016)., Conclusion: Delayed (>24 hr after the procedure) high-grade AVB necessitating PP is common after TAVI. QRS duration measured immediately after TAVI was the best independent predictor of PP in this population. Patients with QRS ≤ 128 msec immediately after TAVI had no risk of requiring PP., (Copyright © 2012 Wiley Periodicals, Inc.)

Aims: Global longitudinal strain (GLS) seems accurate for detecting subclinical myocardial dysfunction, and may therefore be used to improve risk stratification for cardiac surgery., Methods and Results: Longitudinal strain (by two-dimensional speckle tracking) was computed in 425 patients [mean age 67 ± 13 years, 69% male, left ventricular ejection fraction (LVEF) 51 ± 13%] referred for cardiac surgery [isolated coronary artery bypass graft (CABG) (n = 155), aortic valve surgery (n = 174), mitral surgery (n = 96)]. GLS (global-ε) was assessed for predicting early postoperative death. Despite a fair correlation between LVEF and global strain (r = -0.73, P < 0.0001), 40% of patients with preserved LVEF (defined as LVEF ≥50%) had abnormal global-ε (defined as global-ε >-16%): -12.8 ± 1.7%, range -15% to -8%. In patients with preserved LVEF, NT-proBNP level (983 vs. 541 pg/mL, P = 0.03), heart failure symptoms (NYHA class, 2.2 ± 0.9 vs. 1.9 ± 0.9, P = 0.02), and the need for prolonged (>48 h) inotropic support after surgery (33.3 vs. 21.2%, P = 0.03) were greater when global-ε was impaired. Importantly, despite similar EuroSCORE (9.7 ± 12 vs. 7.7 ± 9%, P = 0.2 for EuroSCORE I and 4.2 ± 6.2 vs. 3.4 ± 4.9%, P = 0.4 for EuroSCORE II), the rate of postoperative death was 2.4-fold (11.8 vs. 4.9%, P = 0.04) in patients with preserved LVEF when global-ε was impaired. Multivariate analysis showed that global-ε is an independent predictor for early postoperative mortality [odds ratio = 1.10 (1.01-1.21)] after adjustment to EuroSCORE., Conclusion: GLS has an incremental value over LVEF for risk stratification in patients referred for cardiac surgery.

The present study sought to assess the effectiveness of local anesthesia with conscious sedation (LACS) during transcatheter aortic valve implantation (TAVI). On its introduction, TAVI was mostly performed with the patient under general anesthesia (GA); however, evidence supporting the use of less-invasive LACS has been increasing. The data from 174 consecutive patients who underwent TAVI by way of the femoral artery from December 2007 to December 2011 were analyzed. GA was mainly used in early phase of the study (n = 44); this was gradually shifted to LACS in the late phase (n = 130). The clinical outcomes were compared for those patients who received GA versus LACS. The incidence and causes of "LACS failure," defined as conversion to GA from LACS during TAVI, were also assessed. The rates of procedural success and 30-day mortality were not different between the 2 groups (93.3% vs 95.3%, p = 0.60; 6.7% vs 7.8%, p = 0.55, respectively). Although the clinical backgrounds of the patients showed differences, these results were not significant after adjusting for other influential confounders. The intensive care unit stay and hospital stay were longer in the GA group than in the LACS group (3.9 ± 2.2 vs 3.3 ± 1.5 days, p = 0.044; and 12.2 ± 8.3 vs 8.1 ± 6.5 days, p = 0.001, respectively). LACS failure occurred in 6 patients (4.6%), and the causes were multifactorial, as follows: cardiac tamponade in 2, cardiac arrest in 2, myocardial infarction in 1, and stroke in 1. In conclusion, transfemoral TAVI with the patient under LACS could be successfully performed in most patients, with the advantage of early recovery, although the perioperative risks involved in the TAVI procedure should be considered., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Aims: 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., Methods and Results: 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 gradient <40 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; P < 0.001). 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., Conclusion: 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.

Background: Normal values and the prognostic significance of right ventricle (RV)-2D strain in chronic heart failure (CHF) patients are unknown., Methods and Results: Between 2005 and 2010, we prospectively enrolled 43 controls and 118 stable CHF patients. Standard echocardiographic variables, tricuspid annular plane systolic excursion, peak systolic velocity of tricuspid annular motion using tissue Doppler imaging, and RV and left ventricle (LV) 2D-strain were measured. The primary outcome was death or emergency transplantation or emergency ventricular assist device implantation or acute heart failure. RV-2D strain was measurable in 39 controls (58±17 years, 50% men), whose median value was 30% (95% confidence interval [95%CI], 39%; 20%); and in 104 CHF patients (80% men, mean age 57±11 years, and mean LV ejection fraction 29%±8%), whose median value was 19% (95%CI, 34%; 9%). During the mean follow-up of 37±14 months, 44 experienced the primary outcome. By Cox proportional hazards multivariate analysis, only RV-2D strain and log B-type natriuretic peptide independently predicted experiencing the primary outcome within the first year. The best RV-2D strain cut-off by receiver-operating characteristics analysis was 21%, and patients with values >21% were at greatest risk (χ(2)-log-rank test=14.1, P<0.0001)., Conclusions: RV-2D strain is a strong independent predictor of severe adverse events in patients with CHF and may be superior to other systolic RV or LV echocardiographic variables.

Aims: To evaluate the use of intracardiac echocardiography probe through oesophageal route (ICE-TEE) for the monitoring of percutaneous foramen ovale (PFO) closure procedure., Methods and Results: The study was conducted in 50 patients divided into two groups: in group I (n = 24), accuracy of ICE-TEE in assessing the inter-atrial septum (IAS) was compared with standard TEE, and in group II, we used ICE-TEE to monitor 26 consecutive patients referred for PFO closure. In group I, IAS was constantly visualized with a close correlation between ICE-TEE and standard TEE for IAS excursion (r = 0.9, P < 0.0001). In group II, ICE-TEE allowed to rule out four patients (three without PFO and one with septal atrial defect associated) and identified three complications during PFO closure procedure (pericardial effusion, inadequate device deployment, and cardiac thrombus). Finally, device implantation was successfully performed in the 22 patients with no residual shunt and thrombus observed after 3 months., Conclusion: ICE-TEE could be used to monitor PFO closure procedure.

Background: Longitudinal myocardial deformation indexes appear superior to left ventricular ejection fraction (LVEF) in assessing myocardial contractility. However, few studies have addressed the prognostic value of longitudinal motion markers (velocity, strain, and strain rate) in predicting outcome in heart failure patients., Methods and Results: The study included 125 consecutive symptomatic heart failure patients (63+/-16 years, 77% male, LVEF=31+/-10%). All patients underwent a complete echocardiographic and clinical examination, and brain natriuretic peptide level was assessed in 93 patients. Longitudinal myocardial velocity by tissue Doppler imaging, global-epsilon, and strain rate by speckle tracking were computed from apical views (4-, 3-, and 2-chambers views) and compared with the occurrence of major adverse cardiac events. On the whole, peak longitudinal velocity, global-epsilon, and strain rate averaged 5+/-2 cm/s (range, 1 to 9), -8+/-3% (range, -3 to -18), and -0.33+/-0.16 s(-1) (range, -0.83 to -0.05), respectively. During the follow-up period (266+/-177 days), major adverse cardiac events occurred in 47 (38%) patients (15 deaths, 29 recurrent heart failure, and 4 heart transplantations). By univariable analysis using Cox model global-epsilon, strain rate, and LVEF were associated with the occurrence of major adverse cardiac events, whereas only global-epsilon remained independently predictive of outcome by multivariate analysis., Conclusions: In the heart failure population, longitudinal global strain by speckle tracking is superior to LVEF and other longitudinal markers in identifying patients with poor outcome.

Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Echocardiography has become the primary non-invasive imaging method for the evaluation of valvular regurgitation. The echocardiographic assessment of valvular regurgitation should integrate quantification of the regurgitation, assessment of the valve anatomy, and function as well as the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation thus largely integrates the results of echocardiography. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing regurgitation.

Exercise testing has an established role in the evaluation of patients with valvular heart disease and can aid clinical decision making. Because symptoms may develop slowly and indolently in chronic valve diseases and are often not recognized by patients and their physicians, the symptomatic, blood pressure, and electrocardiographic responses to exercise can help identify patients who would benefit from early valve repair or replacement. In addition, stress echocardiography has emerged as an important component of stress testing in patients with valvular heart disease, with relevant established and potential applications. Stress echocardiography has the advantages of its wide availability, low cost, and versatility for the assessment of disease severity. The versatile applications of stress echocardiography can be tailored to the individual patient with aortic or mitral valve disease, both before and after valve replacement or repair. Hence, exercise-induced changes in valve hemodynamics, ventricular function, and pulmonary artery pressure, together with exercise capacity and symptomatic responses to exercise, provide the clinician with diagnostic and prognostic information that can contribute to subsequent clinical decisions. Nevertheless, there is a lack of convincing evidence that the results of stress echocardiography lead to clinical decisions that result in better outcomes, and therefore large-scale prospective randomized studies focusing on patient outcomes are needed in the future.

Objectives: This 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)., Background: Patients with LF/LGAS without CR have a high mortality rate with conservative therapy. The benefit of AVR in this subset of patients remains controversial., Methods: Eighty-one consecutive patients with symptomatic calcified LF/LGAS (valve area or=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)., Results: Five-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

Aims: Functional ischaemic mitral regurgitation (IMR) is common in patients with ischaemic left ventricular dysfunction undergoing coronary artery bypass surgery. Although the presence of IMR negatively affects prognosis, the additional benefit of valve repair is debated, particularly with mild IMR at rest. Exercise echocardiography may help identify a subset of patients at higher risk of cardiovascular events by revealing the dynamic component of IMR., Methods: A large prospective, multicentre, non-randomized registry is designed to evaluate the effects of surgery on IMR at rest and on its dynamic component at exercise (z). SIMRAM will enrol approximately 550 patients with IMR in up to 17 centres with clinical and exercise follow-up for 1 year. Three sets of outcomes will be prospectively assessed and several hypotheses will be tested including determinants of adverse outcome and progressive left ventricular remodeling, efficacy of treatment and role of ischaemia on the dynamic consequences of IMR. Enrolment began in November 2006 and is expected to end by early 2008.

The objective of this article is to clarify the advantages and limits of echocardiography, MRI, and CT for the determination of left ventricular (LV) function, emphasising the importance of evaluating global ventricular function. MRI is the reference technique, owing to its precision, reproducibility, and innocuous nature. However, echography is performed much more frequently because it is more widely available and easier to carry out. It is our reference technique in everyday practice. More recently, synchronised multi-slice tomodensitometry has provided dynamic reconstructed images of the left ventricle throughout the cardiac cycle, offering a succession of short axis views covering the entire volume of the ventricle. These acquisitions, in addition to non-invasive coronary angiography, allow the LV ejection fraction to be determined. With MRI, study of the LV function does not require any contrast medium to be injected and makes use of effective semi-automatic segmentation programs.

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 cm(2) (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 < or = 0.85 cm(2)/m(2)) 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.

Objective: The aim of this prospective study was to determine the cardiorespiratory factors associated with dyspnea in patients with sickle cell SS-hemoglobin disease, with a specific interest in lung vascular involvement., Measurements: Forty-nine patients (29 women and 20 men; mean [+/- SD] age: women, 29 +/- 6 years; men, 31 +/- 11 years) underwent direct evaluations (Borg scale evaluation during a 6-min walk test) and indirect evaluations (modified Medical Research Council [MRC]score) of their dyspnea, pulmonary function tests (PFTs) [spirometry, volumes, diffusing capacity of the lung for carbon monoxide (Dlco), diffusing capacity of the alveolar-capillary membrane, and pulmonary capillary blood volume measurements], echocardiography, and biological evaluation., Results: Thirty-four patients complained of significant breathlessness (MRC score, > 1). Indirect and direct evaluations of dyspnea were correlated. PFT results depicted a very mild restrictive pattern (mean total pulmonary capacity, 86 +/- 11% predicted) and an impairment of Dlco (mean Dlco corrected for the degree of anemia, 69 +/- 13% predicted). The statistical analysis demonstrated that dyspnea and exercise performance were closely linked to indexes of Dlco but not with any echocardiographic or biological measure including anemia. Nevertheless, only approximately 25% of the variability was explained by these associations. Despite having a similar history of vasoocclusive crisis events, women had more severe anemia, dyspnea, decreases in Dlco (corrected for the degree of anemia), and a higher capillary blood volume (corrected for alveolar volume) than men., Conclusion: Lung vascular disease contributes to dyspnea and the exercise limitation of patients with sickle cell disease. A sequential assessment of Dlco would therefore constitute one of the objective functional end points for follow-up studies of these patients.

The constantly advancing technology of echocardiography and its widespread usage in the intensive care unit has made it a routine examination in patients with acute myocardial infarction. It has become the reference method for diagnosis and monitoring of certain complications such as pericardial effusion, intra-ventricular thrombosis, ventricular aneurysm and mitral regurgitation. The echocardiographic description of these complications dates back to the 1980s during which prospective studies accurately described the principal abnormalities. These descriptions have not been much improved upon with the advent of new technology. On the other hand, the frequency of these complications assessed in an era when reperfusion by thrombolysis or primary angioplasty was much less common than today, has considerably decreased.

Objectives: We sought to assess the value of transthoracic echocardiography (TTE) using standardized imaging planes for the functional analysis of mitral regurgitation (MR) as well as for postoperative outcome implications., Background: The feasibility of mitral valve repair is based on functional assessment of MR, mainly by transesophageal echocardiography (TEE). Considering the recent advances in TTE imaging, the incremental value of TEE in this setting needs to be re-examined., Methods: Consecutive patients (n = 279; 181 men; median age 68 years [quartiles, 61 to 74]) who underwent surgery for MR were enrolled prospectively in two tertiary care centers. The accuracy of TTE (harmonic imaging) versus TEE for functional assessment of MR was evaluated against surgical findings., Results: Valve repair (n = 237 patients, 85%) or replacement (n = 42) was predicted accurately by TTE in 97% of cases; TEE added significant information for only two patients. In the subgroup of degenerative MR (n = 190), agreement with surgical findings for the localization of prolapsed segments was 91% for TTE (kappa, 0.81) and 93% for TEE (kappa, 0.85) without incremental value of TEE (p = 0.40). Patients with single prolapse of the middle posterior scallop (P2) had a better postoperative outcome as compared with patients who had non-P2 lesions (p = 0.008). Furthermore, mitral replacement predicted by TTE was an independent predictor for postoperative long-term mortality (odds ratio 5.7, 95% confidence interval 1.97 to 16.4, p = 0.001)., Conclusions: In experienced hands, functional assessment of MR by TTE can predict accurately valve repairability and has a strong influence on postoperative outcome. Thus, in most cases preoperative TEE is not mandatory, provided intraoperative TEE is performed.