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Assessing the true severity of aortic stenosis (AS) remains a challenge, particularly when echocardiography yields discordant results. Recent European and American guidelines recommend measuring aortic valve calcium (AVC) by multidetector row computed tomography (MDCT) to improve this assessment. To define, using a standardized MDCT scanning protocol, the optimal AVC load criteria for truly severe AS in patients with concordant echocardiographic findings, to establish the ability of these criteria to predict clinical outcomes, and to investigate their ability to delineate truly severe AS in patients with discordant echocardiographic AS grading. Two hundred and sixty-six patients with moderate-to-severe AS and normal LVEF prospectively underwent MDCT and Doppler-echocardiography to assess AS severity. In patients with concordant AS grading, ROC analysis identified optimal cut-off values for diagnosing severe AS using different AVC load criteria. In these patients, 4-year event-free survival was better with low AVC load (60-63%) by these criteria than with high AVC load (23-26%, log rank < 0.001). Patients with discordant AS grading had higher AVC load than those with moderate AS but lower AVC load than those with severe high-gradient AS. Between 36 and 55% of patients with severe LG-AS met AVC load criteria for severe AS. Although AVC load predicted outcome in these patients as well, its prognostic impact was less than in patients with concordant AS grading. Assessment of AVC load accurately identifies truly severe AS and provides powerful prognostic information. Our data further indicate that patients with discordant AS grading consist in a heterogenous group, as evidenced by their large range of AVC load. MDCT allows to differentiate between truly severe and pseudo-severe AS in this population as well, although the prognostic implications thereof are less pronounced than in patients with concordant AS grading.

Au cours de la pandémie liée au COVID-19, de nombreux patients ont été admis en unité de soins intensifs, mettant en exergue le travail d’une spécialité souvent peu ou mal connue du public. L’insuffisance respiratoire présentée par ces patients, et entrant dans le cadre de la définition de l’ARDS, a nécessité des techniques d’oxygénation et de ventilation non-invasive, invasive et dans les cas les plus sévères d’une assistance extra-corporelle. Ces traitements lourds, associés à des techniques de mobilisation compliquées (décubitus ventral) et aux autres traitements usuels de soins intensifs, chez un nombre important de patients simultanés et dont le pronostic était réservé, a généré une pression importante pour les équipes au lit du malade., [Management of patients with COVID-19-related respiratory failure at the intensive care unit] During the COVID-19 pandemic, many patients have been admitted to intensive care units, thereby highlighting the work of a medical specialty that is often little or poorly known to the public. In these patients, respiratory failure, falling within the definition of acute respiratory distress syndrome, had to be managed using non-invasive and invasive oxygenation and ventilation techniques, and in the most severe cases, using extracorporeal membrane oxygenation. These heavy treatments, combined with complicated mobilization techniques (prone position) and other usual intensive care treatments, had to be delivered simultaneously to a large number of patients with a guarded prognosis, which has put under significant pressure the bedside care teams.

OBJECTIVES: To report current practices regarding mechanical ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) and their association with 6-month outcomes. METHODS: International, multi-center, prospective cohort study of patients undergoing ECMO for ARDS during a one-year period in 23 international intensive care units (ICUs). MEASUREMENTS AND MAIN RESULTS: We collected demographics, daily pre- and per-ECMO mechanical ventilation settings and use of adjunctive therapies, ICU- and 6-month-outcome data for 350 patients (median ± standard deviation pre-ECMO PaO2/FiO2 71±34 mmHg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. Tidal volume (6.4±2.0 vs 3.7±2.0 ml/kg), plateau pressure (32±7 vs 24±7cmH2O), driving pressure (20±7 vs. 14±4 cmH2O), respiratory rate (26±8 vs 14±6 breaths/min) and mechanical power (26.1±12.7 vs. 6.6±4.8 J/min) were markedly reduced after ECMO initiation. Six-month survival was 61%. No association was found between ventilator settings during the first 2 days of ECMO and survival in multivariable analysis. A time-varying Cox model retained older age, higher fluid balance, higher lactate, and more need for renal replacement therapy along the ECMO course as being independently associated with 6-month mortality. A higher tidal volume and lower driving pressure (likely markers of static compliance improvement) across the ECMO course were also associated with better outcomes. CONCLUSION: Ultra-protective lung ventilation on ECMO was largely adopted across medium to high case-volume ECMO centers. In contrast with previous observations, mechanical ventilation settings during ECMO did not impact patients' prognosis in this context.

OBJECTIVES: The present study aimed at investigating the respective contribution of afterload and myocardial fibrosis to pre- and post-operative left ventricular (LV) function by using stress-strain relationships. BACKGROUND: Separating the effect of myocardial dysfunction and afterload on pump performance has important implications for the prognosis and management of patients with severe aortic stenosis (AS). METHODS: A total of 101 patients with isolated severe AS (57% men; mean age 71 years) and 75 healthy control subjects underwent resting 2-dimensional and speckle-tracking echocardiography to measure global circumferential strain (GCS) and global longitudinal strain (GLS), as well as end-systolic wall stress (ESWS). Normal stress-strain relationships were constructed using control subjects' data and fitted to linear regression. End-systolic stress-strain indexes (the number of SDs from the mean regression line) were used as an afterload-independent index of myocardial function and compared with myocardial fibrosis, measured on transmural myocardial biopsies harvested at the time of surgery. RESULTS: GCS and GLS were afterload-dependent in both control subjects and patients. The GLS-ESWS relationship of patients was shifted downward compared with control subjects. Patients with reduced pre-operative end-systolic stress-strain indexes exhibited larger degrees of interstitial myocardial fibrosis than patients without (3.8 ± 2.9% vs. 8.3 ± 6.3%, p < 0.001; and 4.9 ± 4.4% vs. 9.5 ± 6.4%; p < 0.001, for GLS and GCS, respectively). By multivariate analysis, pre-operative end-systolic stress-strain indexes were the only predictors of post-operative longitudinal and circumferential end-systolic stress-strain indexes (ß = 0.49 and ß = 0.60, respectively; p < 0.001). CONCLUSIONS: Myocardial strains are afterload-dependent. In patients with severe AS, pre-operative stress-strain indexes allow identification of patients with increased myocardial fibrosis and predict the ext

AIMS: The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) European Endocarditis (EURO-ENDO) registry aims to study the care and outcomes of patients diagnosed with infective endocarditis (IE) and compare findings with recommendations from the 2015 ESC Clinical Practice Guidelines for the management of IE and data from the 2001 Euro Heart Survey. METHODS AND RESULTS: Patients (n = 3116) aged over 18 years with a diagnosis of IE based on the ESC 2015 IE diagnostic criteria were prospectively identified between 1 January 2016 and 31 March 2018. Individual patient data were collected across 156 centres and 40 countries. The primary endpoint is all-cause mortality in hospital and at 1 year. Secondary endpoints are 1-year morbidity (all-cause hospitalization, any cardiac surgery, and IE relapse), the clinical, epidemiological, microbiological, and therapeutic characteristics of patients, the number and timing of non-invasive imaging techniques, and adherence to recommendations as stated in the 2015 ESC Clinical Practice Guidelines for the management of IE. CONCLUSION: EURO-ENDO is an international registry of care and outcomes of patients hospitalized with IE which will provide insights into the contemporary profile and management of patients with this challenging disease.

A 74-year-old woman had an atrial fibrillation (AF) ablation procedure. Three weeks later, she presented with sepsis and paresis of the left upper limb. Initial chest computed tomography (CT) was inconclusive (Fig. 1a, b). Brain magnetic resonance imaging (MRI) showed acute multiple embolic cerebral infarcts (Fig. 1c, d). An atrio-oesophageal fistula (AOF) was suspected. ECG-gated CT was performed (Fig. 1e, f), confirming the diagnosis.[...]

Dear Editor, The accessory cardiac bronchus (ACB) is the only true supernumerary variant bronchus with an incidence between 0.07% and 0.5% [1]. ACB usually originates from the inner wall of the intermediate bronchus or from the right main bronchus, almost opposite to the orifice of the right upper lobe bronchus [1], [2], [3]. To our knowledge, only a single ACB originating from a left bronchus has been reported in literature using bronchography [4]. [...]

The optimal timing of aortic valve replacement in patients with severe aortic stenosis is not widely agreed upon. On the basis of retrospective autopsy data, it is generally believed that the prognosis of patients with no or minimal symptoms is relatively benign and that surgery can be safely delayed until symptoms develop (1). Accordingly, both the American Heart Association (AHA) and American College of Cardiology (ACC) and the European Society of Cardiology (ESC) guidelines consider symptomatic severe aortic stenosis as a class 1 indication for valve replacement but remain quite hesitant as to the optimal strategy to be adopted in asymptomatic patients [...]

Cannabinoid hyperemesis syndrome (CHS) is a clinical condition that was first described in 2004. The syndrome may occasionally be observed in long-term cannabis users and is characterized by a set of features: severe cyclic nausea and vomiting, recurrent epigastric or periumbilical pain, relief of symptoms with hot baths, and cannabis use cessation. The pathophysiology is not fully understood but is probably related to Cannabinoid-1 (CB-1) receptors dysregulation. On the other hand, there is also growing epidemiological evidence that cannabis smoking may trigger acute coronary syndrome (ACS) in young men. We describe the case of 41-year-old man with a long history of cannabis smoking who not only complained of recurrent epigastric but also of retrosternal pain. He had undergone several negative radiological or endoscopic investigations. During the last episode, electrocardiographic and echocardiographic changes were consistent with takotsubo cardiomyopathy. However, the patient was readmitted very soon with a ST-elevation myocardial infarction related to coronary vasospasm. While the link between CHS and ACS is not established, CHS patients with atypical pain should be investigated carefully to exclude any serious cardiac event.

BACKGROUND: The pathophysiology of paradoxical low-gradient (LG) severe aortic stenosis (SAS) remains controversial. As low transvalvular flow has been implicated, we sought to investigate the impact of left ventricular outflow tract (LVOT) ellipticity on the estimation of the LV stroke volume, the calculation of the aortic valve area (AVA) by use of the continuity equation and on AS severity grading. METHODS: We studied 190 consecutive patients (mean age: 72 ± 13 years; male: 57%) with SAS (indexed AVA < 0.6 cm2/m2) and preserved LV ejection fraction, including 120 patients with severe high gradient (HG) AS and 70 with severe paradoxical LG-AS. AS severity, LV volumes and LVOT ellipticity were assessed by 2D-Doppler echocardiography and cardiac magnetic resonance (CMR). RESULTS: The LVOT exhibited an elliptical shape on CMR images, with a shorter anterior-posterior than median-lateral diameter (2.2 ± 0.2 vs 2.8 ± 0.3 cm, p < 0.01). Accordingly, the LVOT area measured by planimetry was larger than by 2D-echocardiography, assuming a circular orifice (4.9 ± 0.9 cm2 vs 3.7 ± 0.8 cm2, p < 0.01). Inputting the elliptical LVOT area into the continuity equation resulted in a 29% increase in the indexed AVA (from 0.41 ± 0.09 cm2 to 0.54 ± 0.10 cm2). Accordingly, 30 (43%) patients with severe paradoxical LG-SAS were reclassified as having moderate AS. Similar results were obtained when considering 3D-echo for direct planimetry of the LVOT in a subset of 75 patients. CONCLUSIONS: Our results confirm that the LVOT is elliptical in shape and that taking this parameter into account in the calculation of the AVA results in reclassification of 43% of patients with severe paradoxical LG-AS into moderate AS.

This thesis focuses on evaluation of clinical, echocardiographic and demographic guidelines criteria to perform aortic valve replacement in patients with severe aortic stenosis, in light of postoperative outcome., (MED - Sciences médicales) -- UCL, 2014

BACKGROUND: First described in 2005, inverted takotsubo is one of the four stress-induced cardiomyopathy patterns. It is rarely associated with subarachnoid hemorrhage but was not previously reported after intraparenchymal bleeding. PURPOSE: We reported a symptomatic case of inverted takotsubo pattern following a cerebellar hemorrhage. CASE REPORT: A 26-year-old woman presented to the emergency department with sudden headache and hemorrhage of the posterior fossa was diagnosed, probably caused by a vascular malformation. Several hours later, she developed acute pulmonary edema due to acute heart failure. Echocardiography showed left ventricular dysfunction with hypokinetic basal segments and hyperkinetic apex corresponding to inverted takotsubo. Outcome was spontaneously favorable within a few days. CONCLUSION: Inverted takotsubo pattern is a stress-induced cardiomyopathy that could be encountered in patients with subarachnoid hemorrhage and is generally of good prognosis. We described the first case following a cerebellar hematoma.

Background- Recent works using echocardiography suggested that low gradient (LG), low flow (LF) aortic stenosis (AS) has more pronounced left ventricular (LV) concentric remodeling, smaller LV cavity size, and more interstitial fibrosis compared with high gradient (HG) normal flow (NF) AS. Therefore, we evaluated the accuracy of echocardiographic measurements and compared remodeling and fibrosis in different types of AS by cardiac magnetic resonance (CMR). Methods and Results- A total of 128 patients (73±11 years of age; 75 men) with aortic valve area (AVA) <0.6 cm(2)/m(2) and ejection fraction >50% by echocardiography underwent CMR to measure planimetric AVA, phase-contrast indexed stroke volume, LV mass, and focal fibrosis. Using <40 mm Hg and indexed stroke volume <35 mL/m(2) by echocardiography as criteria for LG and LF, 69 (54%) patients were HG/NF, 28 (22%) HG/LF, 17 (13%) LG/NF, and 14 (11%) LG/LF AS. LV outflow tract area, indexed stroke volume, and AVA correlated well between echocardiography and CMR (r=0.7, 0.61, and 0.65, respectively; P<0.001 for all). By CMR, however, planimetric AVA was larger in LF/LG (0.54±0.08 cm(2)/m(2)) and LG/NF (0.61±0.08 cm(2)/m(2)) than in HG/LF (0.46±0.07 cm(2)/m(2); P<0.05) AS, and indexed LV mass was lower in LG/LF (75±12 g/m(2)) and LG/NF (81±18 g/m(2)) than in HG/LF (100±27 g/m(2); P<0.05) AS. All groups of AS had similar LV volumes, predominantly concentric hypertrophy remodeling, and similar amounts of focal fibrosis. Conclusions- CMR confirmed overall accuracy of echocardiographic classification of AS but demonstrated that LG/LF and LG/NF AS have larger AVA, less LV hypertrophy, and similar focal fibrosis compared with HG/LF AS. This challenges the view that LG/LF AS is a more advanced state of AS.

Background: Several previous studies have demonstrated that, in patients with severe aortic stenosis (SAS), chronic pressure overload hypertrophy frequently results in reduced longitudinal function as assessed by tissue Doppler or speckle tracking echocardiography (STE). The aim of the present study was to determine the relative contribution of structural (interstitial fibrosis) and functional (afterload) alterations in this process and to evaluate the implications thereof for functional recovery after aortic valve replacement (AVR). Methods: 34 patients with isolated SAS underwent pre-operative resting conventional echocardiography and STE, to calculate end-systolic wall stress (ESS) and to measure global longitudinal strain (GLS) and left ventricular ejection fraction (LVEF). At the time of AVR, a per-operative transmural biopsy was obtained in every patient, to quantify the degree of interstitial fibrosis. Echocardiographic functional parameters were reassessed 6 months after AVR. Results: Compared to age-matched normal controls, SAS patients exhibited significantly reduced GLS (-12.5 ± 3.9% vs -18.2 ± 1.5% p<0.0001) and LVEF (57 ± 13 vs 66 ± 4%, p=0.026). With univariate analysis, pre-operative GLS was found to correlate significantly with LVEF (r=0.70, p<0.0001), interstitial fibrosis (r=-0.60, p=0.0002), LV mass (r=-0.52, p=0.002) and ESS (r=-0.61, p=0.0001). Using stepwise multiple regression analysis, only the degree of interstitial fibrosis and ESS were found to be independent correlates of pre-operative GLS (r=0.74). Interestingly,unstressed pre-operative GLS, extrapolated as GLS at zero stress, correlated well with interstitial fibrosis (r=0.51) and predicted GLS at the 6-months post-operative follow-up (r=0.55). Conclusions: In patients with SAS, reduced longitudinal function results from both excessive afterload and structural tissue alterations (interstitial fibrosis). Unstressed pre-operative GLS was found to be a reasonable correlate of tissue fibros

AIMS: The aim of this study was to evaluate predictors of recovery after balloon aortic valvuloplasty (BAV) among patients with aortic stenosis and depressed left ventricular ejection fraction (LVEF). Predictors for recovery after BAV are not clearly defined. B-type natriuretic peptide (BNP) predicts outcome after surgical and transcatheter aortic valve replacement. METHODS AND RESULTS: Among 151 consecutive patients treated in our institution by BAV, a total of 59 with poor LVEF underwent an echocardiography at 1 month. In these 59 patients, LVEF significantly improved in 22 patients (group 1) from 27 ± 5% to 45 ± 6% (P<.0001) and remained unchanged in 37 patients (group 2) from 29 ± 8% to 30 ± 11% (P=NS). BNP plasma levels at 24 hours only decreased in group 1 from 2170 ± 967 pg/mL to 1208 ± 662 pg/mL (P=.001). By multivariate analysis, BNP reduction >300 pg/mL was the strongest independent predictor of LVEF improvement at 30 days (hazard ratio, 5.459; 95% confidence interval, 1.580-18.860; P=.007). Kaplan-Meier analysis showed that 1-year survival after BAV was significantly higher in patients of group 1 than in group 2 (95 ± 4% vs 51 ± 8%, respectively; P=.02). CONCLUSIONS: BAV in patients with poor left ventricular function resulted in LVEF improvement at 30 days in 37% of cases, which was detected by a reduction of BNP levels already seen at 24 hours. Survival at 1 year was significantly higher in patients with such an improved LVEF after BAV.

Objectives: The purpose of this study was to evaluate the impact of focal fibrosis (FF) assessment by delayed-enhanced cardiac magnetic resonance (DE-CMR) on survival in patients with severe aortic stenosis (AS) treated by aortic valve replacement (AVR). Background: Prior studies have shown that DE-CMR predicts survival in severe aortic valve disease. However in context of curative surgery, FF impact is less known as well as influence of coronary status. Methods: The authors prospectively evaluated survival of 180 consecutive patients (118 males, age 72±9.5 years) with AVR undergoing DE-CMR. One hundred twenty four patients underwent isolated AVR, whereas 56 patients received associated coronary artery bypass graft (CABG). Results: Over the 3-year median follow-up, 21 patients died. Mean FF percentage was higher in patients with events versus those without (3.9±5.1 vs. 1.5±2.6, 0.001). Kaplan-Meier analyses revealed that higher degrees of FF were associated with worse long-term survival after AVR with or without associated CABG (chi-square = 3.58, p 0.05; chi-square = 4.15, p 0.04, respectively). On multivariable cox analysis, FF (hazard ratio [HR]: 1.12 (1.0-1.2), 95% confidence interval [CI]: 1.0 to 1.2, p < 0.004) and New York Heart Association functional class (HR: 2.0, 95% CI: 1.1 to 3.5, p < 0.01) were identified as strong independent determinants of poor prognosis. In patients with AS, there were 3 findings for FF distributed as follows between patients with events versus those without: no enhancement (67 vs. 42, p <0.02), infarct pattern (22 vs. 33, p =NS), and midwall enhancement (10 vs. 23, p =NS). However after exclusion of 67 patients with CAD history, prognostic value of FF was decreased (log rank=NS). Conclusions: With or without revascularization, presence of FF by DE-CMR is an independent predictor of mortality in patients AVR with AS. DE-CMR provides additional information in the evaluation of preoperative risk particularly for patients with CAD his

Aims: To assess the accuracy of the recently proposed echocardiographic classification system of aortic stenosis (AS), and to evaluate differences between patients with high (HG) and low gradient (LG) and normal (NF) and low flow (LF) AS in terms of AS severity, LV remodeling and fibrosis using cardiovascular magnetic resonance (CMR). Methods and results: 128 consecutive patients (73±11 years, 95 male) with aortic valve area (AVA) <0.6 cm/m2 and ejection fraction >50% by echocardiography underwent evaluation of planimetric AVA, phase contrast indexed stroke volume (SVI), left ventricular hypertrophy, and focal fibrosis by CMR. Using <40 mm Hg, and SVI <35 ml/m2 as criteria for LG and LF respectively, 69 (54%) patients were HG/NF, 28 (22%) HG/LF, 17 (13%) LG/NF, and 14 (11%) LG/LF AS. Measurements of LVOT area, SVI and AVA correlated well between echocardiography and CMR (r=0.7, 0.61, 0.65, respectively; p<0.001 for all). Planimetric AVA by MRI was less severe in LF/LG (0.54±0.08 cm2/m2) and NF/LG (0.61±0.08 cm2/m2) than in HG/LF (0.46±0.07 cm2/m2, p<0.05) AS. Also indexed mass was less in LF/LG (75±12 g/m2) and LG/NF (81±18 g/m2) than in HG/LF (100±27 g/m2, p<0.05) AS. All groups of AS had predominantly concentric hypertrophy remodeling, and similar amounts of focal fibrosis (1.6±3.9%, 1.5±2.2%, 0.8±0.7% and 1.0±1.3% for HG/NF HG/LF, LG/NF and LG/LF groups respectively p=NS) Conclusions: CMR confirmed that echocardiographic classification system of AS was overall accurate. Patients with paradoxical LG/LF and LG/NF AS had less severe AS severity, less hypertrophy and similar remodeling and similar amount of focal fibrosis than HG/LF AS.

Background. For patients with aortic regurgitation (AR), aortic valve (AV) repair represents as an attractive alternative to AV replacement (R), as it does not expose the patients to the risk of prosthetic valve complications. Although the durability of AV repair has been documented, its superiority to prosthetic AVR has not yet been established. Methods. We examined the outcome of 317 consecutive patients who underwent surgical correction of severe AR between 1995 and 2010, of whom 264 underwent AV repair and 53 AVR. Results. Operative mortality was similar in the AV repair and AVR groups (1% vs 4%, p=0.19). Kaplan Meier survival analysis indicated a significantly better overall 6-year survival after AV repair than after AVR (88% vs 69%, log rank p=0.0002). These differences persisted after age adjustment. Cox's proportional survival analysis demonstrated that the choice of treatment was an independent predictor of post-operative survival. To reduce the effect of selection bias, we matched 49 pairs of patients using a propensity score. For these 98 propensity-score matched patients, overall survival remained significantly better after AV repair than after AVR (83% vs 68%, log rank p=0.037). Finally, the improved survival after AV repair was not offset by an increased reoperation rate as re-operation free survival was similar in the 2 groups (96% vs 98%, log rank p=0.52). Conclusion. AV repair significantly improves postoperative outcomes in patients with AR and whenever feasible, should probably be the preferred mode of surgical correction.

Background. Aortic stenosis (AS) is a common valve disease in octogenarians. Previous studies have shown that aortic valve replacement (AVR) is frequently not performed in these patients. The aim of the present study was to investigate the incidence, determinants and prognostic impact of AVR denial in these patients. Method. Between 2000 and 2007, 163 octogenarians (mean age 84±3 years) with severe AS and an indication for surgery according to guidelines were prospectively included in an echocardiographic registry. Among these patients, 97 underwent AVR, whereas 66 were treated conservatively. Results. Logistic regression analysis identified older age, a lower transaortic pressure gradient, a larger aortic valve area and the presence of diabetes as independent predictors of AVR refusal or denial. In patients undergoing AVR, 30-day mortality was 9%. Overall 5-year survival was better in AVR patients than in those treated conservatively (66% vs 31%, log rank p<0.001 vs. AVR). After adjustment for the propensity score, patients undergoing AVR still had a better outcome than conservatively treated patients (p=0.022, HR:0.56, 95%CI [0.29-0.91]). Finally, in addition to the therapeutic decision, Cox regression analysis also identified a low body weight, a NYHA class III/IV, and the logistic EuroScore as independent predictors of outcome in the overall series Conclusion. About 40% of octogenarians with severe AS and a definite indication for surgery either refuse or are denied AVR. AVR refusal or denial has a profound impact on long-term prognosis as it results in a 2-fold excess mortality, even after adjustment for the propensity score.

BACKGROUND: It remains incompletely understood whether patients with transfusion related cardiac iron overload without signs of heart failure exhibit already subclinical alterations of systolic left ventricular (LV) dysfunction. Therefore we performed a comprehensive evaluation of systolic and diastolic cardiac function in such patients using tagged and phase-contrast CMR. METHODS: 19 patients requiring regular blood transfusions for chronic anemia and 8 healthy volunteers were investigated using cine, tagged, and phase-contrast and T2* CMR. LV ejection fraction, peak filling rate, end-systolic global midventricular systolic Eulerian radial thickening and shortening strains as well as left ventricular rotation and twist, mitral E and A wave velocity, and tissue e' wave and E/e' wave velocity ratio, as well as isovolumic relaxation time and E wave deceleration time were computed and compared to cardiac T2*. RESULTS: Patients without significant iron overload (T2*>20 ms, n=9) had similar parameters of systolic and diastolic function as normal controls, whereas patients with severe iron overload (T2*<10 ms, n=5), had significant reduction of LV ejection fraction (54+/-2% vs. 62+/-6% and 65+/-6% respectively p<0.05), of end-systolic radial thickening (+6+/-4% vs. +11+/-2 and +11+/-4% respectively p<0.05) and of rotational twist (1.6+/-0.2 degrees vs. 3.0+/-1.2 and 3.5+/-0.7 degrees respectively, p<0.05) than patients without iron overload (T2*>20 ms) or normal controls. Patients with moderate iron overload (T2* 10-20 ms, n=5), had preserved ejection fraction (59+/-6%, p=NS vs. pts. with T2*>20 ms and controls), but showed reduced maximal LV rotational twist (1.8+/-0.4 degrees). The magnitude of reduction of LV twist (r=0.64, p<0.001), of LV ejection fraction (r=0.44, p<0.001), of peak radial thickening (r=0.58, p<0.001) and of systolic (r=0.50, p<0.05) and diastolic twist and untwist rate (r=-0.53, p<0.001) in patients were directly correlated to the logarithm

Background: The 2008 ACC/AHA Guidelines categorize patients (pts) with severe aortic stenosis (AS, aortic valve area < 1cm2), in 2 groups: high gradient high velocity (HGHV, mean transvalvular gradient (MG) >40 mmHg and velocity >4 m/s), and low flow low gradient AS (LFLG, MG <30 mmHg and low cardiac output). This potentially leaves a significant number of SAS pts unclassified (UAS). To overcome this limitation, the category of paradoxical low flow AS (PLF, ejection fraction ≥ 50% and indexed stroke volume ≤35 ml/m2) was introduced. The aim of this study was to evaluate the amount of overlap between this new AS category and the ACC/AHA AS categories and to investigate how the various definitions of AS impact on prognosis after aortic valve replacement (AVR). Methods: From a prospective registry, all 863 pts (age 75±7 years) with AS who underwent AVR between 2000-2010 were followed. Pts were categorised in 3 groups based on the 2008 ACC/AHA guidelines and the amount of overlap with PLF was calculated. Hospital and long term Kaplan Meier survival curves were constructed for each group. Multivariate Cox analysis were computed to evaluate predictors of survival. Results: Mean follow up is 38 months. Based on the 2008 ACC/AHA Guidelines, 22% of pts with AS were unclassified (n=189), i.e. were neither HGHV (n=610, 71%) nor LFLG (n=64, 7%). Pts with PLF AS (n=285) overlapped with these 3 categories and amounted for 66% of HGHV, 10% of LFLG and 24% of UAS. Survival analysis indicated that HGHV, PLF AS and UAS have similarly good post operative hospital survival (94% and 95%, p=0.41), while LFLG AS had worse survival (87%, p=0.019). Multivariate Cox Analysis identified LFLG AS as predictor of hospital mortality (p=0.008). Long Term survival analysis indicated that HGHV and UAS have a different outcome (at 60 months: 86% and 73% respectively; p=0.035). PLF classification was not discriminant for the survival (p=0.14). Conslusion: The current classification of AS is confusing

Background: Prior studies have shown that patients with severe aortic stenosis (AS) have myocardial fibrosis secondary to chronic pressure overload. The aim of the present study was to analyze the prevalence of interstitial fibrosis by gadolinium contrast late enhanced (LE) magnetic resonance imaging in a cohort of patients with severe AS, yet without coronary artery disease, and to determine which hemodynamic or echocardiographic parameters predict such LE. Methods: We studied 45 consecutive patients with severe AS (valve area < 1cm2, maximum velocity > 4 m/s), and clinical indication of valve replacement. Only patients without significant coronary stenosis, history of myocardial infarction or cardiac surgery were considered. All patients underwent LE-MRI and 2D transthoracic echocardiography. Presence and extent of LE, thought to represent myocardial fibrosis was evaluated using an automated detection software (Segment). Significant fibrosis was considered as LE > mean + 2SD of healthy volunteers (i.e. 1% myocardial mass). A logistic regression model was used to evaluate which clinical, hemodynamic and echocardiographic parameters correlated with presence of significant fibrosis in AS. Results: Indexed aortic valve area was 0.36±0.09cm2/m2, aortic valve resistance was 356±270 dyne/s/cm5, energy loss index was 0.42±0.12cm2/m2 and valvulo-arterial impedance was 5.2±2.0mmHg/ml/m2. Significant LE was found in 33% patients with AS (mean LE value 2.65±1.51%), and was predominantly located in inferior segments. By univariate analysis, the only predictive factors for the presence of LE in AS were indexed LV mass (80±26 versus 63±18g/m2, p=0.01) and creatinine level (1.20±0.31 versus 0.99±0.21mg%, p=0.01). In multivariate analysis, only indexed LV mass measured by MRI was found to correlate with presence of LE (p=0.002). Conclusion: Small amounts of LE, indicating diffuse myocardial fibrosis is present in one third of patients with AS without coronary artery disease. Prese

Background: Transcatheter Aortic Valve Implantation (TAVI) has recently emerged as an attractive alternative for treating patients with severe aortic stenosis (AS) who are not candidate for conventional aortic valve replacement. Because TAVI prosthesis are quite expensive and not every patient in whom they are implanted benefit from the procedure, we aimed at investigating if any preimplantation patient's characteristics would help predicting an unfavorable outcome after TAVI. Methods: Between January 2008 and May 2010, 70 consecutive patients with severe AS (31 women; mean age: 84 ± 5years) underwent TAVI using the Edwards-Sapien valve. The clinical outcome was assessed at 1 and 6 months after implantation. Overall and cardiovascular survivals were computed. Logistic and Cox regression analyses were used to identify independent predictors of clinical improvement and/or outcome. Results: 18 patients died during a mean follow-up of 8 months. At 20 months, mean overall survival was 60%. Among the 58 patients who survived up to the 6 months follow-up, 45 were in NYHA class II or less and reported significant clinical improvement, whereas 13 were still in NYHA class III–IV and reported no significant clinical improvement. Cox survival analysis identified age (p<0.026) and renal dysfunction (p<0.029) as independant predictors for mortality. Logistic regression analysis identified LV ejection fraction (p<0.001) and chronic obstructive pulmonary disease (COPD, p=0.078) as being associated with functional improvement at 6 months (see Table). Conclusion: In high risk patients undergoing TAVI, advanced age and renal dysfunction are associated with an increased risk of death, whereas pre-TAVI LV dysfunction and COPD identify patients who are more likely to remain symptomatic after the procedure.

In spite of the fact that severe side effects have been reported, black cohosh [Actaea racemosa (syn. Cimifuga racemosa)] is likely to be one of the most popular herbs used in the treatment of postmenopausal symptoms and menstrual dysfunction. We report the cases of two patients, one with submassive liver necrosis and the other with chronic hepatitis most likely related to the use of two different preparations containing black cohosh. This represents another advice for caution concerning this popular preparation of inconsistent therapeutic value.

This report concerns a patient with symptomatic lung metastases from an epithelial-myoepithelial carcinoma of the submandibular gland. Although the efficacy of chemotherapy is unknown in this disease, our patient was treated with cisplatin combined with 5-fluorouracil and later with paclitaxel and cyclophosphamide. Chemotherapy allowed disease stabilization and relief of the pulmonary symptoms. This is the first report on the use of chemotherapy in this very rare salivary gland carcinoma.