Publications by authors named "Christophe Tribouilloy"

255 Publications

Changes in Plasma Angiopoietin Levels After Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement: A Prospective Cohort Study.

J Cardiothorac Vasc Anesth 2021 Mar 21. Epub 2021 Mar 21.

Department of Anaesthesiology and Critical Care Medicine, Dijon University Hospital, Dijon, France.

Objective: Angiopoietins (Angs) regulate endothelial permeability. Ang-1 and 2 (Ang-1 and Ang-2) are implied in endothelial stability through an antagonism effect. The objectives of the present study were to describe and compare changes in Ang levels after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).

Design: A prospective, single-center study.

Participants: Adult patients with aortic stenosis scheduled for SAVR or TAVR.

Interventions: None.

Measurements And Main Results: Ang-1 and Ang-2 were measured using an enzyme-linked immunosorbent assay right before surgery (T0), at the end of surgery (T1), and at day one (T2). Sixty consecutive patients (SAVR group [n = 30] and TAVR group [n = 30]) were included between January and June 2017. Ang-1 decreased significantly after both TAVR (T0: 3,663 [2,602-4,262]; T1: 1,611 [981-2,409]; T2: 1,082 [652-1,589] ng/mL; p < 0.0001) and SAVR (T0: 1,603 [975-2,849]; T1: 783 [547-1,024]; T2: 828 [460-1,227] ng/mL; p = 0.0001). Ang-2 increased significantly after SAVR (T0: 2,472 [1,502-3,622]; T1: 2,997 [1,759-3,839]; T2: 5,421 [3,557-7,087] ng/mL; p < 0.0001) but did not change markedly after TAVR (T0: 3,343 [2,661-6,272]; T1: 3,788 [2,574-5,016]; T2: 3,446 [3,029-6,313] ng/mL; p = 0.066). Among patients with paravalvular leakage, the changes in the plasma Ang-2 level and the Ang-2/Ang-1 ratio were greater.

Conclusion: SAVR induces greater alterations of Ang homeostasis than TAVR, confirming a role for the use of cardiopulmonary bypass. Paravalvular leakage after TAVR is associated with Ang changes similar to those observed with SAVR.
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http://dx.doi.org/10.1053/j.jvca.2021.03.025DOI Listing
March 2021

Aortic Stenosis Progression, Cardiac Damage, and Survival: Comparison Between Bicuspid and Tricuspid Aortic Valves.

JACC Cardiovasc Imaging 2021 Jun 17;14(6):1113-1126. Epub 2021 Mar 17.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Objectives: This study sought to compare aortic stenosis (AS) progression rates, AS-related cardiac damage (AS-CD) indicator incidence and determinants, and survival between patients with tricuspid aortic valve (TAV)-AS and those with bicuspid aortic valve (BAV)-AS.

Background: Differences in AS progression and AS-CD between patients with BAV and patients with TAV are unknown.

Methods: We retrospectively studied consecutive patients with baseline peak aortic valve velocity (peakV) ≥2.5 m/s and left ventricular ejection fraction ≥50%. Follow-up echocardiograms (n = 4,818) provided multiparametric AS progression rates and AS-CD.

Results: The study included 330 BAV (age 54 ± 14 years) and 581 patients with TAV (age 72 ± 11 years). At last echocardiogram (median: 5.9 years; interquartile range: 3.9 to 8.5 years), BAV-AS exhibited similar peakV and mean pressure gradient (MPG) as TAV-AS, but larger calculated aortic valve area due to larger aortic annulus (p < 0.0001). Multiparametric progression rates were similar between BAV-AS and TAV-AS (all p ≥ 0.08) and did not predict age-/sex-adjusted survival (p ≥ 0.45). Independent determinants of rapid progression were male sex and baseline AS severity for TAV (all p ≤ 0.024), and age, baseline AS severity, and cardiac risk factors (age interaction: p = 0.02) for BAV (all p ≤ 0.005). At 12 years, patients with TAV-AS had a higher incidence of AS-CD than BAV-AS patients (p < 0.0001), resulting in significantly worse survival compared to BAV-AS (p < 0.0001). AS-CD were independently determined by multiple factors (MPG, age, sex, comorbidities, cardiac function; all p ≤ 0.039), and BAV was independently protective of most AS-CD (all p ≤ 0.05).

Conclusions: In this cohort, TAV-AS and BAV-AS progression rates were similar. Rapid progression did not affect survival and was determined by cardiac risk factors for BAV-AS (particularly in patients with BAV <60 years of age) and unmodifiable factors for TAV-AS. AS-CD and mortality were significantly higher in TAV-AS. Independent determinants of AS-CD were multifactorial, and BAV morphology was AS-CD protective. Therefore, the totality of AS burden (cardiac damage) is clinically crucial for TAV-AS, whereas attention to modifiable risk factors may be preventive for BAV-AS.
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http://dx.doi.org/10.1016/j.jcmg.2021.01.017DOI Listing
June 2021

Non-contrast myocardial T1 global and regional reference values at 3 Tesla cardiac magnetic resonance in aortic stenosis.

Arch Cardiovasc Dis 2021 Apr 11;114(4):293-304. Epub 2021 Mar 11.

Monaco cardiothoracic centre, 11 bis, avenue d'Ostende, 98000 MC, Monaco. Electronic address:

Background: T1 mapping using cardiac magnetic resonance (CMR) was recently proposed as a promising non-contrast imaging technique for the assessment of diffuse myocardial fibrosis (MF) in aortic stenosis (AS).

Aims: To provide reference values for native T1 mapping at 3 Tesla magnetic field strength in subjects with moderate or severe AS and in control subjects; to identify factors associated with the presence of diffuse MF in severe AS; to assess the regional distribution of diffuse MF; and to compare the level of diffuse MF in the different types of AS, stratified by flow and gradient patterns.

Methods: Retrospective study based on 160 consecutive patients with moderate (n=11) to severe (n=149) AS and 47 control subjects referred for CMR.

Results: Mean native T1 increased progressively across controls (1221±23ms), moderate AS (1249±26ms) and severe AS (1273±43ms). T1 times correlated significantly with left ventricular (LV) remodelling (indexed LV mass and LV diastolic volume) and functional LV alterations (global longitudinal strain and LV ejection fraction). Native T1 appears to be elevated in the basal segments of the septum in moderate AS, and to extend to midventricular and apical segments in severe AS. Mean T1 time was higher in classical low-flow/low-gradient AS (1295±62ms) than in the other types of AS (P=0.006). The level of diffuse MF in paradoxical low-flow/low-gradient AS (1280±42ms) was higher than in moderate AS, but similar to that in high-gradient AS (1271±42ms) (P=0.07).

Conclusions: Assessment of diffuse MF in AS using T1 mapping is feasible and reproducible in clinical practice. T1 value increases with AS severity, along with morphological and functional LV alterations, particularly in the basal segments of the septum.
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http://dx.doi.org/10.1016/j.acvd.2020.11.009DOI Listing
April 2021

Echocardiographic assessment of aortic stenosis: a practical guideline from the British Society of Echocardiography.

Echo Res Pract 2021 Apr 28;8(1):G19-G59. Epub 2021 Apr 28.

University Hospital Amiens, Amiens, France.

The guideline provides a practical step-by-step guide in order to facilitate high-quality echocardiographic studies of patients with aortic stenosis. In addition, it addresses commonly encountered yet challenging clinical scenarios and covers the use of advanced echocardiographic techniques, including TOE and Dobutamine stress echocardiography in the assessment of aortic stenosis.
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http://dx.doi.org/10.1530/ERP-20-0035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8115410PMC
April 2021

Clinical Outcomes of Adults With Bicuspid Aortic Valve: A European Perspective.

Mayo Clin Proc 2021 03;96(3):648-657

Department of Cardiology, Amiens University Hospital, France; EA 7517 MP3CV Université de Picardie Jules Verne, Amiens, France. Electronic address:

Objective: To describe the clinical history of patients with a wide age range diagnosed with bicuspid aortic valve (BAV) and no surgical indication and to evaluate the long-term outcome of patients with BAV referred for elective surgery.

Patients And Methods: Between 2005 and 2017, 350 consecutive patients with no surgical indication (surveillance group, mean age 53±16, 71% men) and 191 with a surgical indication (surgical group, mean age 59±13, 71% men) were prospectively included. Median follow-up was 80 (32 to 115) months.

Results: In the surveillance group, the 5-year and 10-year survival rates were 93±1% and 89±2%, respectively, with a relative survival of patients with BAV compared with an age- and sex-matched control population of 98.7%. During follow-up, the cumulative 10-year incidence of aortic valve and aorta surgery was high; of 35±4%, the incidence of native valve infective endocarditis (IE) of 0.2% per patient-year, and no cases of aortic dissection were observed. In the surgical group, the 5-year and 10-year survival rates were 97±1% and 89±3%, respectively, with a relative survival of 99.4% compared with the general population. The incidence of IE was 0.4% per patient-year, and no cases of aortic dissection were observed.

Conclusion: This regional cohort shows that the 10-year survival rates of patients with BAV and a wide age range, but mostly middle-aged adults, were similar to those of the general population with a very low rate of complications. Adherence to prophylactic surgical indications and younger age might have contributed to this lack of difference.
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http://dx.doi.org/10.1016/j.mayocp.2020.04.047DOI Listing
March 2021

Acceleration Time in Aortic Stenosis: A New Life for an Old Parameter.

Circ Cardiovasc Imaging 2021 Jan 19;14(1):e012234. Epub 2021 Jan 19.

Groupement des Hôpitaux de l'Institut Catholique de Lille, Department of Cardiology, Lille Catholic University, France (S.M.).

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http://dx.doi.org/10.1161/CIRCIMAGING.120.012234DOI Listing
January 2021

Clinical and prognostic implications of phenomapping in patients with heart failure receiving cardiac resynchronization therapy.

Arch Cardiovasc Dis 2021 Mar 8;114(3):197-210. Epub 2021 Jan 8.

Cardiology Department, Lille Catholic Hospitals, Lille Catholic University, 59160 Lomme, France; Laboratory MP3CV-EA 7517, University Centre for Health Research, Picardy University, 80000 Amiens, France. Electronic address:

Background: Despite having an indication for cardiac resynchronization therapy according to current guidelines, patients with heart failure with reduced ejection fraction who receive cardiac resynchronization therapy do not consistently derive benefit from it.

Aim: To determine whether unsupervised clustering analysis (phenomapping) can identify distinct phenogroups of patients with differential outcomes among cardiac resynchronization therapy recipients from routine clinical practice.

Methods: We used unsupervised hierarchical cluster analysis of phenotypic data after data reduction (55 clinical, biological and echocardiographic variables) to define new phenogroups among 328 patients with heart failure with reduced ejection fraction from routine clinical practice enrolled before cardiac resynchronization therapy. Clinical outcomes and cardiac resynchronization therapy response rate were studied according to phenogroups.

Results: Although all patients met the recommended criteria for cardiac resynchronization therapy implantation, phenomapping analysis classified study participants into four phenogroups that differed distinctively in clinical, biological, electrocardiographic and echocardiographic characteristics and outcomes. Patients from phenogroups 1 and 2 had the most improved outcome in terms of mortality, associated with cardiac resynchronization therapy response rates of 81% and 78%, respectively. In contrast, patients from phenogroups 3 and 4 had cardiac resynchronization therapy response rates of 39% and 59%, respectively, and the worst outcome, with a considerably increased risk of mortality compared with patients from phenogroup 1 (hazard ratio 3.23, 95% confidence interval 1.9-5.5 and hazard ratio 2.49, 95% confidence interval 1.38-4.50, respectively).

Conclusions: Among patients with heart failure with reduced ejection fraction with an indication for cardiac resynchronization therapy from routine clinical practice, phenomapping identifies subgroups of patients with differential clinical, biological and echocardiographic features strongly linked to divergent outcomes and responses to cardiac resynchronization therapy. This approach may help to identify patients who will derive most benefit from cardiac resynchronization therapy in "individualized" clinical practice.
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http://dx.doi.org/10.1016/j.acvd.2020.07.004DOI Listing
March 2021

Excess Mortality and Undertreatment of Women With Severe Aortic Stenosis.

J Am Heart Assoc 2021 Jan 29;10(1):e018816. Epub 2020 Dec 29.

Division of Cardiology Mayo Clinic Rochester MN.

Background Although women represent half of the population burden of aortic stenosis (AS), little is known whether sex affects the presentation, management, and outcome of patients with AS. Methods and Results In a cohort of 2429 patients with severe AS (49.5% women) we aimed to evaluate 5-year excess mortality and performance of aortic valve replacement (AVR) stratified by sex. At presentation, women were older (<0.001), with less comorbidities (=0.030) and more often symptomatic (=0.007) than men. Women had smaller aortic valve area (<0.001) than men but similar mean transaortic pressure gradient (=0.18). The 5-year survival was lower compared with expected survival, especially for women (62±2% versus 71% for women and 69±1% versus 71% for men). Despite longer life expectancy in women than men, women had lower 5-year survival than men (66±2% [expected-75%] versus 68±2% [expected-70%], <0.001) after matching for age. Overall, 5-year AVR incidence was 79±2% for men versus 70±2% for women (<0.001) with male sex being independently associated with more frequent early AVR performance (odds ratio, 1.49; 1.18-1.97). After age matching, women remained more often symptomatic (=0.004) but also displayed lower AVR use (64.4% versus 69.1%; =0.018). Conclusions Women with severe AS are diagnosed at later ages and have more symptoms than men. Despite prevalent symptoms, AVR is less often performed in women and 5-year excess mortality is noted in women versus men, even after age matching. These imbalances should be addressed to ensure that both sexes receive equivalent care for severe AS.
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http://dx.doi.org/10.1161/JAHA.120.018816DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955469PMC
January 2021

Doppler Echocardiographic Indices Are Specific But Not Sensitive to Predict Pulmonary Artery Occlusion Pressure in Critically Ill Patients Under Mechanical Ventilation.

Crit Care Med 2021 01;49(1):e1-e10

Medical Intensive Care Unit and INSERM U1088, Amiens University Hospital, Amiens, France.

Objectives: The objective of this study was to prospectively evaluate the ability of transthoracic echocardiography to assess pulmonary artery occlusion pressure in mechanically ventilated critically ill patients.

Design: In a prospective observational study.

Setting: Amiens University Hospital Medical ICU.

Patients: Fifty-three mechanically ventilated patients in sinus rhythm admitted to our ICU.

Intervention: Transthoracic echocardiography was performed simultaneously to pulmonary artery catheter.

Measurements And Main Results: Transmitral early velocity wave recorded using pulsed wave Doppler (E), late transmitral velocity wave recorded using pulsed wave Doppler (A), and deceleration time of E wave were recorded using pulsed Doppler as well as early mitral annulus velocity wave recorded using tissue Doppler imaging (E'). Pulmonary artery occlusion pressure was measured simultaneously using pulmonary artery catheter. There was a significant correlation between pulmonary artery occlusion pressure and lateral ratio between E wave and E' (E/E' ratio) (r = 0.35; p < 0.01), ratio between E wave and A wave (E/A ratio) (r = 0.41; p < 0.002), and deceleration time of E wave (r = -0.34; p < 0.02). E/E' greater than 15 was predictive of pulmonary artery occlusion pressure greater than or equal to 18 mm Hg with a sensitivity of 25% and a specificity of 95%, whereas E/E' less than 7 was predictive of pulmonary artery occlusion pressure less than 18 mm Hg with a sensitivity of 32% and a specificity of 81%. E/A greater than 1.8 yielded a sensitivity of 44% and a specificity of 95% to predict pulmonary artery occlusion pressure greater than or equal to 18 mm Hg, whereas E/A less than 0.7 was predictive of pulmonary artery occlusion pressure less than 18 mm Hg with a sensitivity of 19% and a specificity of 94%. A similar predictive capacity was observed when the analysis was confined to patients with EF less than 50%. A large proportion of E/E' measurements 32 (60%) were situated between the two cut-off values obtained by the receiver operating characteristic curves: E/E' greater than 15 and E/E' less than 7.

Conclusions: In mechanically ventilated critically ill patients, Doppler transthoracic echocardiography indices are highly specific but not sensitive to estimate pulmonary artery occlusion pressure.
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http://dx.doi.org/10.1097/CCM.0000000000004702DOI Listing
January 2021

Epidemiological Features of Aortic Stenosis in a French Nationwide Study: 10-Year Trends and New Challenges.

J Am Heart Assoc 2020 12 23;9(23):e017588. Epub 2020 Nov 23.

Santé Publique France French Public Health Agency Saint-Maurice France.

Background Aortic stenosis (AS) is one of the most common forms of valvular heart disease. Our aim was to estimate the burden of AS in the hospital in France, describe patient characteristics, and evaluate the mortality rate and temporal trends. Methods and Results All patients hospitalized for AS in France between 2006 and 2016 were identified from the national hospital discharge database. Patients' sociodemographic, medical, and surgical characteristics and temporal trends were described. All AS-related deaths between 2000 and 2014 were identified using death certificates. In 2016, 26 071 patients were hospitalized for AS: 56.5% were men with an average age of 77 years. The all-cause mortality rate at 1 year postindex stay was 11%. The rate of patients hospitalized for AS increased by 59% between 2006 and 2016, reaching 38.7/100 000 person-years in 2016. This increase was most pronounced in patients aged >75 years. The number of transcatheter aortic valve implantations increased following their introduction in 2010. In 2016, 44% of patients were treated with aortic valve surgery during the index hospital stay or following year (mean age, 71.5 years), and 34% were treated with transcatheter aortic valve implantation (mean age, 83.0 years). In 2014, 6186 deaths caused by AS were identified in death certificates: 41.6% were men with an average age of 87 years. The age-standardized mortality rate increased by 5% between 2000 and 2014, reaching 8.5/100 000 person-years in 2014. Conclusions The rate of patients hospitalized for AS increased in recent years in line with the higher life expectancy and introduction of transcatheter aortic valve implantation. Mortality increased more moderately.
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http://dx.doi.org/10.1161/JAHA.120.017588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763773PMC
December 2020

Normative Reference Values of Cardiac Output by Pulsed-Wave Doppler Echocardiography in Adults.

Am J Cardiol 2021 02 2;140:128-133. Epub 2020 Nov 2.

Pôle Coeur-Thorax-Vaisseaux, Department of Cardiology, University Hospital Amiens, Amiens, France; EA 7517, MP3CV, Jules Verne University of Picardie, Amiens, France. Electronic address:

Cardiac output (CO) is routinely assessed by pulsed-wave Doppler echocardiography, yet reference values in adults are lacking. We aim to establish normative values of CO and cardiac index (CI) by pulsed-wave Doppler-echocardiography and to analyze their relation with gender and age in nonobese and obese adults. We included 4,040 adults (mean age: 55 years, 53% women, 950 obese [body mass index ≥30 kg/m²]) with normal blood pressure, no history of cardiovascular disease, and normal transthoracic echocardiography. Normative reference CO and CI values for were calculated in 3,090 nonobese patients by quantile regression. CO normal limits were lower in females than in males (lower limit: 3.3 vs 3.5 L/min, upper limit: 7.3 vs 8.2 L/min). CI normal limits were identical for both genders (lower limit: 1.9 L/min/m², upper limit: 4.3 L/min/m²). Although the relation of CO to age was weak and observed only in women, CI of both genders was not influenced by age. CO of obese patients was significantly greater than that of their nonobese counterparts. CI of obese patients was not influenced by age and gender and was not significantly different than that of nonobese patients (lower limit 1.8 L/min/m², upper limit 4.1 L/min/m² for both genders). In conclusion, in a large adult population we establish normative reference values for CO and CI measured by Doppler-echocardiography. CI is a remarkably stable parameter that is not influenced by age, gender, and body size and should be used to define low- and high-output states.
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http://dx.doi.org/10.1016/j.amjcard.2020.10.046DOI Listing
February 2021

Dimensionless Index in Patients With Low-Gradient Severe Aortic Stenosis and Preserved Ejection Fraction.

Circ Cardiovasc Imaging 2020 10 20;13(10):e010925. Epub 2020 Oct 20.

Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, Service de Cardiologie Nord, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, France (A.A., N.T., W.M., B.L., P.P., S.M.).

Background Risk stratification of patients with low-gradient (LG) severe aortic stenosis (AS) despite preserved left ventricular ejection fraction remains challenging. We sought to evaluate the relationship between the dimensionless index (DI)-the ratio of the left ventricular outflow tract time-velocity integral to that of the aortic valve jet-and mortality in these patients. Methods Seven hundred fifty-five patients with LG severe AS (defined by aortic valve area ≤1 cm or aortic valve area indexed to body surface area ≤0.6 cm/m and mean aortic pressure gradient <40 mm Hg) and preserved left ventricular ejection fraction ≥50% were studied. Flow status was defined according to stroke volume index <35 mL/m (low flow, LF) or ≥35 mL/m (normal flow, NF). Results After adjustment for age, sex, body mass index, Charlson comorbidity index, history of hypertension, history of atrial fibrillation, AS-related symptoms, left ventricular ejection fraction, indexed left ventricular ventricular mass, aortic valve area, and aortic valve replacement as a time-dependent covariate, patients with LG-LF and DI<0.25 exhibited a considerable increased risk of death compared with patients with LG-NF and DI≥0.25 (adjusted hazard ratio, 2.41 [95% CI, 1.61-3.62]; <0.001), LG-NF and DI<0.25 (adjusted hazard ratio, 1.84 [95% CI, 1.24-2.73]; =0.003), and LG-LF and D≥0.25 (adjusted hazard ratio, 2.27 [95% CI, 1.42-3.63]; <0.001). In contrast, patients with LG-LF and DI≥0.25, LG-NF and DI<0.25, and LG-NF and DI≥0.25 had similar outcome. DI<0.25 showed incremental prognostic value in patients with LG-LF severe AS but not in patients with LG-NF severe AS. Conclusions Among patients with LG severe AS and preserved left ventricular ejection fraction, decreased DI<0.25 is a reliable parameter in patients with LF to identify a subgroup of patients at higher risk of death who may derive benefit from aortic valve replacement.
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http://dx.doi.org/10.1161/CIRCIMAGING.120.010925DOI Listing
October 2020

Isolated tricuspid valve surgery: impact of aetiology and clinical presentation on outcomes.

Eur Heart J 2020 12;41(45):4304-4317

Department of Cardiology, University of Ottawa Heart Institute, 40 ruskin street, Ottawa, Ontario, Canada.

Aims: The aim of this study was to identify determinants of in-hospital and mid-term outcomes after isolated tricuspid valve surgery (ITVS) and more specifically the impact of tricuspid regurgitation (TR) mechanism and clinical presentation.

Methods And Results: Among 5661 consecutive adult patients who underwent a tricuspid valve (TV) surgery at 12 French tertiary centres in 2007-2017 collected from a mandatory administrative database, we identified 466 patients (8% of all tricuspid surgeries) who underwent an ITVS. Most patients presented with advanced disease [47% in New York Heart Association (NYHA) III/IV, 57% with right-sided heart failure (HF) signs]. Tricuspid regurgitation was functional in 49% (22% with prior left-sided heart valve surgery and 27% isolated) and organic in 51% (infective endocarditis in 31% and other causes in 20%). In-hospital mortality and major complications rates were 10% and 31%, respectively. Rates of survival and survival free of HF readmission were 75% and 62% at 5 years. Patients with functional TR incurred a worse in-hospital mortality than those with organic TR (14% vs. 6%, P = 0.004), but presentation was more severe. Independent determinants of outcomes were NYHA Class III/IV [odd ratios (OR) = 2.7 (1.2-6.1), P = 0.01], moderate/severe right ventricular dysfunction [OR = 2.6 (1.2-5.8), P = 0.02], lower prothrombin time [OR = 0.98 (0.96-0.99), P = 0.008], and with borderline statistical significance, right-sided HF signs [OR = 2.4 (0.9-6.5), P = 0.06] while TR mechanism was not [OR = 0.7 (0.3-1.8), P = 0.88].

Conclusion: Isolated TV surgery was associated with high mortality and morbidity, both in hospital and during follow-up, predicted by the severity of the presentation but not by TR mechanism. Our results suggest that TV intervention should be performed earlier in the course of the disease.
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http://dx.doi.org/10.1093/eurheartj/ehaa643DOI Listing
December 2020

Severe Aortic Stenosis and Chronic Kidney Disease: Outcomes and Impact of Aortic Valve Replacement.

J Am Heart Assoc 2020 10 23;9(19):e017190. Epub 2020 Sep 23.

Department of Cardiology Amiens University Hospital Amiens France.

Background The prognostic significance of chronic kidney disease (CKD) in severe aortic stenosis is poorly understood and no studies have yet evaluated the effect of aortic-valve replacement (AVR) versus conservative management on long-term mortality by stage of CKD. Methods and Results We included 4119 patients with severe aortic stenosis. The population was divided into 4 groups according to the baseline estimated glomerular filtration rate: no CKD, mild CKD, moderate CKD, and severe CKD. The 5-year survival rate was 71±1% for patients without CKD, 62±2% for those with mild CKD, 54±3% for those with moderate CKD, and 34±4% for those with severe CKD (<0.001). By multivariable analysis, patients with moderate or severe CKD had a significantly higher risk of all-cause (hazard ratio [HR] [95% CI]=1.36 [1.08-1.71]; =0.009 and HR [95% CI]=2.16 [1.67-2.79]; <0.001, respectively) and cardiovascular mortality (HR [95% CI]=1.39 [1.03-1.88]; =0.031 and HR [95% CI]=1.69 [1.18-2.41]; =0.004, respectively) than patients without CKD. Despite more symptoms, AVR was less frequent in moderate (=0.002) and severe CKD (<0.001). AVR was associated with a marked reduction in all-cause and cardiovascular mortality versus conservative management for each CKD group (all <0.001). The joint-test showed no interaction between AVR and CKD stages (=0.676) indicating a nondifferentialeffect of AVR across stages of CKD. After propensity matching, AVR was still associated with substantially better survival for each CKD stage relative to conservative management (all <0.0017). Conclusions In severe aortic stenosis, moderate and severe CKD are associated with increased mortality and decreased referral to AVR. AVR markedly reduces all-cause and cardiovascular mortality, regardless of the CKD stage. Therefore, CKD should not discourage physicians from considering AVR.
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http://dx.doi.org/10.1161/JAHA.120.017190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792421PMC
October 2020

Impact of Mitral Regurgitation Severity and Left Ventricular Remodeling on Outcome After MitraClip Implantation: Results From the Mitra-FR Trial.

JACC Cardiovasc Imaging 2021 Apr 16;14(4):742-752. Epub 2020 Sep 16.

Hopital Cardiovasculaire Louis Pradel, Chirurgie Cardio-Vasculaire et Transplantation Cardiaque, Hospices Civils de Lyon and Claude Bernard University, Lyon, France. Electronic address:

Objectives: This study aimed to identify a subset of patients based on echocardiographic parameters who might have benefited from transcatheter correction using the MitraClip system in the MITRA-FR (Percutaneous Repair with the MitraClip Device for Severe Functional/Secondary Mitral Regurgitation) trial.

Background: It has been suggested that differences in the degree of mitral regurgitation (MR) and left ventricular (LV) remodeling may explain the conflicting results between the MITRA-FR and the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trials.

Methods: In a post hoc analysis, we evaluated the interaction between the intervention and subsets of patients defined based on MR severity (effective regurgitant orifice [ERO], regurgitant volume [RVOL] and regurgitant fraction [RF]), LV remodeling (end-diastolic and end-systolic diameters and volumes) and combination of these parameters with respect to the composite of death from any cause or unplanned hospitalization for heart failure at 24 months.

Results: We observed a neutral impact of the intervention in subsets with the highest MR degree (ERO ≥30 mm, RVOL ≥45 ml or RF ≥50%) as in patients with milder MR degree. The same was seen in subsets with the milder LV remodeling using either diastolic or systolic diameters or volumes. When parameters of MR severity and LV remodeling were combined, there was still no benefit of the intervention including in the subset of patients with an ERO/end-diastolic volume ratio ≥ 0.15 despite similar ERO and LV end-diastolic volume compared with COAPT patients.

Conclusions: In the MITRA-FR trial, we could not identify a subset of patients defined based on the degree of the regurgitation, LV remodeling or on their combination, including those deemed as having disproportionate MR, that might have benefited from transcatheter correction using the MitraClip system. (Multicentre Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation [MITRA-FR]; NCT01920698).
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http://dx.doi.org/10.1016/j.jcmg.2020.07.021DOI Listing
April 2021

Prognostic Importance of Left Ventricular Global Longitudinal Strain in Patients with Severe Aortic Stenosis and Preserved Ejection Fraction.

J Am Soc Echocardiogr 2020 12 9;33(12):1454-1464. Epub 2020 Sep 9.

Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, services de cardiologies, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France; Centre Universitaire de Recherche en Santé, Laboratoire MP3CV-EA 7517, Université de Picardie, Amiens, France. Electronic address:

Background: Impaired left ventricular (LV) speckle-tracking-derived global longitudinal strain (GLS) magnitude (GLS worse than 14.7%) has been associated with poor outcome in patients with severe aortic stenosis (AS) and preserved LV ejection fraction (EF).

Objectives: To test the hypothesis that GLS magnitude ≤ 15% obtained with vendor-independent speckle-tracking strain software may be able to identify patients with severe AS who are at higher risk of death, despite preserved LVEF and no or mild symptoms.

Methods: GLS was retrospectively obtained in 332 patients with severe AS (aortic valve area indexed [AVAi] < 0.6 cm/m), no or mild symptoms, and LVEF ≥ 50%. Absolute values of GLS were collected. Survival analyses were carried out to study the impact of GLS magnitude on all-cause mortality.

Results: During a median follow-up period of 42 (37-46) months, 105 patients died. On multivariate analysis, and after adjustment of known clinical and/or echocardiographic predictors of outcome and aortic valve replacement as a time-dependent covariate, GLS magnitude ≤ 15% was independently associated with mortality during follow-up (all P < .01). Adding GLS magnitude ≤ 15% (adjusted hazard ratio = 1.99 [1.17-3.38], P = .011) to a multivariate model including clinical and echocardiographic variables of prognostic importance (aortic valve replacement, aortic valve area, LV stroke volume index < 30 mL/m, and LVEF<60%) improved the predictive performance with improved global model fit, reclassification, and better discrimination. After propensity score matching (n = 196), increased risk of mortality persisted among patients with GLS magnitude ≤ 15% compared with those with GLS > 15% (hazard ratio = 2.10; 95% confidence interval, 1.20-3.68; P = .009).

Conclusions: In this series of patients with severe AS, no or mild symptoms, and LVEF ≥ 50%, GLS obtained with vendor-independent speckle-tracking strain software was an effective tool to identify patients with a poor outcome. Detection of myocardial dysfunction by identifying GLS magnitude < 15% in patients with severe AS, no or mild symptoms, and LVEF ≥ 50%, can aid in risk assessment.
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http://dx.doi.org/10.1016/j.echo.2020.07.002DOI Listing
December 2020

Estimation of Pulmonary Artery Occlusion Pressure Using Doppler Echocardiography in Mechanically Ventilated Patients.

Crit Care Med 2020 10;48(10):e943-e950

Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France.

Objectives: Evaluation of left atrial pressure is frequently required for mechanically ventilated critically ill patients. The objective of the present study was to evaluate the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for assessment of the pulmonary artery occlusion pressure (a frequent surrogate of left atrial pressure) in this population.

Design: A pooled analysis of three prospective cohorts of patients simultaneously assessed with a pulmonary artery catheter and echocardiography.

Settings: Medical-surgical intensive care department of two university hospitals in France.

Patients: Mechanically ventilated critically ill patients.

Interventions: None.

Measurements And Main Results: Of 98 included patients (males: 67%; mean ± SD age: 59 ± 16; and mean Simplified Acute Physiology Score 2: 54 ± 20), 53 (54%) experienced septic shock. Using the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines, the predicted pulmonary artery occlusion pressure was indeterminate in 48 of the 98 patients (49%). Of the 24 patients with an elevated predicted left atrial pressure (grade II/III diastolic dysfunction), only 17 (71%) had a pulmonary artery occlusion pressure greater than or equal to 18 mm Hg. Similarly, 20 of the 26 patients (77%) with a normal predicted left atrial pressure (grade I diastolic dysfunction) had a measured pulmonary artery occlusion pressure less than 18 mm Hg. The sensitivity and specificity of American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for predicting elevated pulmonary artery occlusion pressure were both 74%. The agreement between echocardiography and the pulmonary artery catheter was moderate (Cohen's Kappa, 0.48; 95% CI, 0.39-0.70). In a proposed alternative algorithm, the best echocardiographic predictors of a normal pulmonary artery occlusion pressure were a lateral e'-wave greater than 8 (for a left ventricular ejection fraction ≥ 45%) or an E/A ratio less than or equal to 1.5 (for a left ventricular ejection fraction < 45%).

Conclusions: The American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines do not accurately assess pulmonary artery occlusion pressure in ventilated critically ill patients. Simple Doppler measurements gave a similar level of diagnostic performance with less uncertainly.
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http://dx.doi.org/10.1097/CCM.0000000000004512DOI Listing
October 2020

Estimation of Pulmonary Artery Occlusion Pressure Using Doppler Echocardiography in Mechanically Ventilated Patients.

Crit Care Med 2020 10;48(10):e943-e950

Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France.

Objectives: Evaluation of left atrial pressure is frequently required for mechanically ventilated critically ill patients. The objective of the present study was to evaluate the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for assessment of the pulmonary artery occlusion pressure (a frequent surrogate of left atrial pressure) in this population.

Design: A pooled analysis of three prospective cohorts of patients simultaneously assessed with a pulmonary artery catheter and echocardiography.

Settings: Medical-surgical intensive care department of two university hospitals in France.

Patients: Mechanically ventilated critically ill patients.

Interventions: None.

Measurements And Main Results: Of 98 included patients (males: 67%; mean ± SD age: 59 ± 16; and mean Simplified Acute Physiology Score 2: 54 ± 20), 53 (54%) experienced septic shock. Using the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines, the predicted pulmonary artery occlusion pressure was indeterminate in 48 of the 98 patients (49%). Of the 24 patients with an elevated predicted left atrial pressure (grade II/III diastolic dysfunction), only 17 (71%) had a pulmonary artery occlusion pressure greater than or equal to 18 mm Hg. Similarly, 20 of the 26 patients (77%) with a normal predicted left atrial pressure (grade I diastolic dysfunction) had a measured pulmonary artery occlusion pressure less than 18 mm Hg. The sensitivity and specificity of American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for predicting elevated pulmonary artery occlusion pressure were both 74%. The agreement between echocardiography and the pulmonary artery catheter was moderate (Cohen's Kappa, 0.48; 95% CI, 0.39-0.70). In a proposed alternative algorithm, the best echocardiographic predictors of a normal pulmonary artery occlusion pressure were a lateral e'-wave greater than 8 (for a left ventricular ejection fraction ≥ 45%) or an E/A ratio less than or equal to 1.5 (for a left ventricular ejection fraction < 45%).

Conclusions: The American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines do not accurately assess pulmonary artery occlusion pressure in ventilated critically ill patients. Simple Doppler measurements gave a similar level of diagnostic performance with less uncertainly.
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http://dx.doi.org/10.1097/CCM.0000000000004512DOI Listing
October 2020

Characteristics and Prognosis of Patients With Left-Sided Native Bivalvular Infective Endocarditis.

Can J Cardiol 2021 02 9;37(2):292-299. Epub 2020 Apr 9.

Department of Cardiology, Amiens University Hospital, Amiens, France; UR UPJV 7517, Jules Verne University of Picardie, Amiens, France. Electronic address:

Background: Most cases of left-sided native valve infective endocarditis (IE) involve a single valve and little is known concerning IE that simultaneously affects the aortic and mitral valves.

Methods: We aimed to determine the characteristics, identify the prognostic factors, and define the effect of early surgery for patients with left-sided native bivalvular IE. This analysis included 1340 consecutive patients who presented with definite acute left-sided native valve IE in a 2-centre cohort study.

Results: A bivalvular involvement was present in 257 patients (19%). Patients with bivalvular IE had more embolic events (P = 0.044), congestive heart failure (P = 0.016), vegetations, and perivalvular complications (both P < 0.001) than those with monovalvular IE. Early surgery was more frequent for patients with bivalvular IE (P < 0.001). Thirty-day mortality was higher for patients with bivalvular IE than for those with monovalvular IE (24.5% vs 17.6%; P = 0.008), even after adjustment (odds ratio, 1.86 [95% confidence interval, 1.26-2.73]; P < 0.001). Estimated 10-year survival was 70% ± 1% for monovalvular IE and 59% ± 3% for bivalvular IE (P = 0.002). Bivalvular IE was still associated with mortality in multivariable Cox analysis, after adjustment for covariates including age, neurological events, congestive heart failure, Staphylococcus spp infection, perivalvular complications, and early surgery (hazard ratio, 1.70 [95% confidence interval, 1.31-2.11]; P < 0.001). Early surgery was associated with increased survival for patients with bivalvular IE (79% ± 4% vs 35% ± 6%; P < 0.001).

Conclusions: Bivalvular involvement is frequent in left-sided native valve IE, is associated with more embolic events and congestive heart failure than monovalvular IE, and patients are at a high risk of death. Early surgery is associated with improved survival and should be systematically discussed in the absence of contraindication.
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http://dx.doi.org/10.1016/j.cjca.2020.03.046DOI Listing
February 2021

Improvement of the Prognosis Assessment of Severe Tricuspid Regurgitation by the Use of a Five-Grade Classification of Severity.

Am J Cardiol 2020 10 30;132:119-125. Epub 2020 Jun 30.

Department of Cardiology, Amiens University Hospital, Amiens, France; UR UPJV 7517, Jules Verne University of Picardie, Amiens, France. Electronic address:

It is well known that some patients present with "more than severe" tricuspid regurgitation (TR). We aimed to assess the prognosis of these very severe TR patients. We defined very severe TR using 3 simple echocardiographic parameters: a coaptation gap≥10mm, a laminar TR flow and a systolic reversal of the hepatic vein flow. We included 259 consecutive patients (76 ± 13 years; 46% men) with moderate-to-severe TR (n = 114) and severe TR (n = 145). The primary end point was the combination of hospitalisation for right heart failure (RHF) and cardiovascular mortality. Median follow-up was 24(7 to 47) months. In patients with severe TR, 52 (36%) met the definition of very severe TR. These patients were younger, had more history of RHF and were more frequently treated with loop diuretics than those with moderate-to-severe TR (all p < 0.001). Four-year event-free survival rates were 68 ± 5%, for moderate-to-severe TR, 48 ± 6% for severe TR and only 35 ± 7% for very-severe TR (p < 0.001). On multivariable analysis, after adjustment for outcome predictors including age, comorbidity, RHF, TR etiology, left and right ventricular dysfunction, and tricuspid valve surgery, patients with very severe TR had a worsened prognosis than those with moderate-to-severe TR (Adjusted Hazard Ratio [95% Confidence Interval] = 2.43 [1.18 to 5.53]; p = 0.002) and than those with severe TR (Adjusted Hazard Ratio [95% Confidence Interval] = 2.23 [1.06 to 5.56]; p = 0.015). In conclusion, very severe TR is frequent in patients with severe TR, corresponds to a more advanced stage of the disease and is associated with poor outcomes. Therefore, the use of a 5-grade classification of TR severity is justified in routine clinical practice. (ID-RCB: 2017-A03233-50).
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http://dx.doi.org/10.1016/j.amjcard.2020.06.044DOI Listing
October 2020

Mitral Regurgitation in Patients With Severe Aortic Regurgitation: When Misery Loves Company.

J Am Coll Cardiol 2020 07;76(3):247-250

Department of Cardiology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium.

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http://dx.doi.org/10.1016/j.jacc.2020.05.055DOI Listing
July 2020

Progression of Normal Flow Low Gradient "Severe" Aortic Stenosis With Preserved Left Ventricular Ejection Fraction.

Am J Cardiol 2020 08 16;128:151-158. Epub 2020 May 16.

Department of Cardiology, Amiens University Hospital, Amiens, France; UR UPJV 7517, Jules Verne University of Picardie, Amiens, France. Electronic address:

Normal-flow low-gradient severe aortic stenosis (NF-LG-SAS), defined by an aortic valve area (AVA) <1 cm², mean pressure gradient (MPG) <40 mm Hg and indexed stroke volume ≥35 ml/m², is the most prevalent form of low-gradient aortic stenosis (AS) with preserved ejection fraction (PEF). However, the true severity of AS in these patients is controversial. The aim of this Doppler echocardiographic study was to investigate changes over time in the hemodynamic severity of patients with NF-LG-SAS with PEF. We retrospectively identified 96 patients who had 2 Doppler echocardiographic examinations without an intervening event. After a median follow-up of 25 (interquartile range 15 to 52) months, progression was observed, with increased transaortic MPG (from 28 [25 to 33] to 39 [34 to 50] mm Hg; p<0.001), peak aortic jet velocity (from 3.46 [3.20 to 3.64] to 4.01 [3.70 to 4.39] m/s; p<0.001), and decreased AVA (from 0.87 [0.82 to 0.94] to 0.72 [0.62 to 0.81] cm²; p<0.001). Median annual rates of progression were 4.3 (1.7 to 8.1) mm Hg/year, 0.25 (0.08 to 0.44) m/s/year, and -0.05 (-0.10 to -0.02) cm²/year, respectively. There was no significant change in left ventricular ejection fraction over time (p = 0.74). At follow-up, 46 patients (48%) acquired the features of classical high-gradient severe AS (MPG ≥40 mm Hg). This study shows that most patients with NF-LG-SAS with PEF exhibit significant hemodynamic progression of AS severity without EF impairment. These findings suggest that NF-LG-SAS with PEF is an "intermediate" stage between moderate AS and classical high-gradient severe AS requiring close monitoring.
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http://dx.doi.org/10.1016/j.amjcard.2020.05.003DOI Listing
August 2020

Clinical presentation and outcomes of adults with bicuspid aortic valves: 2020 update.

Prog Cardiovasc Dis 2020 Jul - Aug;63(4):434-441. Epub 2020 May 30.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA. Electronic address:

The congenital bicuspid aortic valve (BAV) is a heterogeneous condition that is better understood considering 3 types of valvulo-aortopathy presentations: A typical-presentation valvulo-aortopathy, a complex-presentation valvulo-aortopathy and an uncomplicated/undiagnosed-presentation. The burden of BAV-related complications has been elucidated in patients with the typical-presentation valvulo-aortopathy and is discussed in this review. These patients enjoy an overall normal expected long-term survival as long as complications are identified and treated in a timely manner. This notion and the fact that the most dreaded complications (infective endocarditis and aortic dissection) are infrequent, represent important reassuring points for the BAV patient. Common complications such as valve dysfunction and aorta dilatation must be the subject of focused research in prevention and treatment. Conversely, BAV patients with complex-presentation valvulo-artopathy, as well as typical valvulo-aortopathy BAV patients who are older, with advanced valvular dysfunction, and possible late-referral to specialized care, may incur a survival penalty as compared to the general population. An evidence-based discussion of these concepts is provided in this review.
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http://dx.doi.org/10.1016/j.pcad.2020.05.010DOI Listing
October 2020

Spondylodiscitis complicating infective endocarditis.

Heart 2020 Dec 28;106(24):1914-1918. Epub 2020 May 28.

Cardiology Department, APHM, La Timone Hospital, Marseille, France

Objective: The primary objective was to assess the characteristics and prognosis of pyogenic spondylodiscitis (PS) in patients with infective endocarditis (IE). The secondary objectives were to assess the factors associated with occurrence of PS.

Methods: Prospective case-control bi-centre study of 1755 patients with definite IE with (n=150) or without (n=1605) PS. Clinical, microbiological and prognostic variables were recorded.

Results: Patients with PS were older (mean age 69.7±18 vs 66.2±14; p=0.004) and had more arterial hypertension (48% vs 34.5%; p<0.001) and autoimmune disease (5% vs 2%; p=0.03) than patients without PS. The lumbar vertebrae were the most frequently involved (84 patients, 66%), especially L4-L5. Neurological symptoms were observed in 59% of patients. Enterococci and were more frequent (24% vs 12% and 24% vs 11%; p<0001, respectively) in the PS group. The diagnosis of PS was based on contrast-enhanced MRI in 92 patients, bone CT in 88 patients and F-FDG PET/CT in 56 patients. In-hospital (16% vs 13.5%, p=0.38) and 1-year (21% vs 22%, p=0.82) mortalities did not differ between patients with or without PS.

Conclusions: PS is a frequent complication of IE (8.5% of IE), is observed in older hypertensive patients with enterococcal or IE, and has a similar prognosis than other forms of IE. Since PS is associated with specific management, multimodality imaging including MRI, CT and PET/CT should be used for early diagnosis of this complication of endocarditis.
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http://dx.doi.org/10.1136/heartjnl-2019-316492DOI Listing
December 2020

Aortic root dilatation in PFO-related cryptogenic stroke: A propensity score-matched analysis.

Echocardiography 2020 06 25;37(6):883-890. Epub 2020 May 25.

Department of Intensive Cardiac Care Unit, Amiens University Hospital, Amiens, France.

Background: Dilatation of the ascending aorta has an important role in the anatomical conformation of interatrial septum (IAS) especially when a patent foramen ovale (PFO) is present. The aim of the study was to investigate the relationship between ascending aortic dilation and PFO-related cryptogenic stroke in a cohort of cryptogenic strokes.

Methods: It is a retrospective, single-center echocardiographic study assessing aortic root dilatation in 315 consecutive patients with cryptogenic stroke between January 2011 and January 2019. Aortic root dilatation was defined by a diameter of the Valsalva sinuses of the proximal aorta >40 mm. Predictive factors of PFO were assessed by a multivariate analysis. Propensity score matching was applied to account for clinical differences.

Results: Of the 315 patients, 68 (22%) had an aortic root dilatation and 167 (53%) had a PFO. In the aortic root dilation group, PFO was more often diagnosed (n = 47/68 [69%], vs n = 120/247 [49%], P = .004). In the PFO group with aortic dilatation, IAS was more mobile (n = 37/47[79%] vs n = 69/120[57%], P < .012) and smaller (2.3 ± 0.5 vs 2.5 ± 0.5 mm, P < .009). On multivariate analysis, aortic root dilatation (OR: 2.6; 95% CI [1.2-5.6]; P = .001) and IAS hypermobility (OR: 5.2 95% CI [2.7-10]; P = .001) were associated with PFO. After propensity matching, aortic root dilatation remained strongly associated with PFO (n = 34/107 [32%] vs 15/107[14%], P = .002).

Conclusion: Aortic root dilation and IAS hypermobility were strongly associated with PFO-related cryptogenic stroke.
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http://dx.doi.org/10.1111/echo.14711DOI Listing
June 2020

Usefulness of Cardiac Magnetic Resonance Imaging in Aortic Stenosis.

Circ Cardiovasc Imaging 2020 05 6;13(5):e010356. Epub 2020 May 6.

Department of Cardiology (Y.B., C.T.), Amiens University Hospital, France.

The objective of this review is to provide an overview of the role of cardiac magnetic resonance (CMR) in aortic stenosis (AS). Although CMR is undeniably the gold standard for assessing left ventricular volume, mass, and function, the assessment of the left ventricular repercussions of AS by CMR is not routinely performed in clinical practice, and its role in evaluating and quantifying AS is not yet well established. CMR is an imaging modality integrating myocardial function and disease, which could be particularly useful in a pathology like AS that should be considered as a global myocardial disease rather than an isolated valve disease. In this review, we discuss the emerging potential of CMR for the diagnosis and prognosis of AS. We detail its utility for studying all aspects of AS, including valve anatomy, flow quantification, left ventricular volumes, mass, remodeling, and function, tissue mapping, and 4-dimensional flow magnetic resonance imaging. We also discuss different clinical situations where CMR could be useful in AS, for example, in low-flow low-gradient AS to confirm the low-flow state and to understand the reason for the left ventricular dysfunction or when there is a suspicion of associated cardiac amyloidosis.
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http://dx.doi.org/10.1161/CIRCIMAGING.119.010356DOI Listing
May 2020

Rational and design of the ROTAS study: a randomized study for the optimal treatment of symptomatic patients with low-gradient severe aortic valve stenosis and preserved left ventricular ejection fraction.

Eur Heart J Cardiovasc Imaging 2021 Jan;22(2):229-235

University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France.

Aims: Fifteen to thirty percentage of patients with severe aortic stenosis (AS) have preserved left ventricular ejection fraction (LVEF) and a discordant AS pattern at Doppler echocardiography, which is characterized by a small (<1 cm2) aortic area and low mean aortic gradient (<40 mmHg). The 'Randomized study for the Optimal Treatment of symptomatic patients with low-gradient severe Aortic Stenosis and preserved left ventricular ejection fraction' (ROTAS trial) aims at demonstrating the superiority of aortic valve replacement vs. a 'watchful waiting strategy' in symptomatic patients with low-gradient (LS), severe AS, and preserved LVEF, stratified according to indexed stroke volume, in terms of all-cause mortality or cardiovascular-related hospitalization during follow-up (FU).

Methods And Results: The ROTAS trial will be a multicentre randomized non-blinded study involving 16 reference centres. AS severity will be confirmed by a multimodality approach (rest and stress echocardiography, calcium scoring, and cardiac magnetic resonance imaging for optimally characterize the population), which could provide important inputs to improve the pathophysiological understanding of this complex disease. Well-characterized patients will be randomized according to the management strategy. The primary endpoint will be the occurrence of all-cause mortality or cardiac related-hospitalizations during 2-year FU. One hundred and eighty subjects per group will be included.

Conclusion: The management of patients with LS severe AS and preserved LVEF is largely debated. ROTAS trial will allow a comprehensive evaluation of this particular pattern of AS and will establish which is the most appropriate management of these patients.
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http://dx.doi.org/10.1093/ehjci/jeaa036DOI Listing
January 2021

Clinical significance of energy loss index in patients with low-gradient severe aortic stenosis and preserved ejection fraction.

Eur Heart J Cardiovasc Imaging 2020 06;21(6):608-615

Cardiology Department, Echocardiography Laboratory, Heart Valve Center, GCS-Groupement des Hôpitaux de l'Institut Catholique Lillois/Faculté de médecine et de maïeutique, UCLille, Rue du Grand But - BP 249 59462 Lomme Cedex, France.

Aims: We hypothesized that among patients with low-gradient severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF), reclassification of AS severity as moderate by pressure recovery adjusted indexed aortic valve area (AVAi) = energy loss index (ELI), may identify a subgroup of patients with a better outcome.

Methods And Results: Three hundred and seventy-nine patients with low-gradient AS (defined by AVAi ≤ 0.6 cm2/m2 and mean aortic pressure gradient < 40 mmHg) and preserved LVEF ≥50% were studied. Reclassification as moderate AS by ELI was defined as AVAi ≤0.6 cm2/m2 but with an ELI >0.6 cm2/m2. Cardiac events [cardiac mortality and/or need for aortic valve replacement (AVR)] during follow-up were studied. One hundred and forty-eight patients (39%) were reclassified as moderate AS by ELI. Reclassification as moderate AS was independently associated with decreased body surface area, normal flow status, decreased left ventricular mass index, and left atrial volume index (all P < 0.05). After adjustment for variables of prognostic interest, reclassification as moderate AS by ELI was associated with a considerable reduction of risk of cardiac events {adjusted hazard ratio (HR) 0.49 [95% confidence interval (CI) 0.33-0.72]; P < 0.001}, need for AVR [adjusted HR 0.52 (95% CI 0.34-0.81); P = 0.004], and cardiac mortality [adjusted HR 0.46 (95% CI 0.22-0.98); P = 0.044].

Conclusion: In patients with low-gradient severe AS and preserved LVEF, calculation of ELI permits to reclassify almost 40% of patients as having moderate AS. These reclassified patients have a considerable reduction of the risk of cardiac events during follow-up. Calculation of ELI is useful for decision-making in patients with low-gradient severe AS and preserved ejection fraction.
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http://dx.doi.org/10.1093/ehjci/jeaa010DOI Listing
June 2020

Impact of Right Ventricular Systolic Dysfunction on Outcome in Aortic Stenosis.

Circ Cardiovasc Imaging 2020 01 21;13(1):e009802. Epub 2020 Jan 21.

Department of Cardiology, Amiens University Hospital, France (Y.B., P.G., D.R., M.K., C.T.).

Background: Pulmonary hypertension is an established outcome predictor in patients with aortic stenosis (AS), but the prognostic impact of right ventricular dysfunction has not been well studied.

Methods: We included 2181 patients (50.4% men; mean age, 77 years) with aortic valve area <1.3 cm and analyzed the occurrence of all-cause death during follow-up according to tricuspid annular plane systolic excursion (TAPSE) quartiles.

Results: Patients in the lowest quartile (TAPSE <17 mm) were at a high risk of death, whereas survival was comparable for the 3 other quartiles. Five-year survival was 55±2% for TAPSE <17 mm, 72±2% for TAPSE of 17 to 20 mm, 71±2% for TAPSE of 20 to 24 mm, and 73±2% for TAPSE >24 mm (overall <0.001). TAPSE <17 mm was associated with increased mortality after adjustment for established prognostic factors (adjusted hazard ratio [HR], 1.55 [95% CI, 1.21-1.97]) and after further adjustment for aortic valve replacement (AVR; adjusted HR, 1.47 [95% CI, 1.15-1.87]). The excess mortality risk associated with TAPSE <17 mm was noticed in both patients managed initially conservatively (adjusted HR, 1.46 [95% CI, 1.20-1.76]) and patients who underwent early (within 3 months after diagnosis) AVR (adjusted HR, 1.61 [95% CI, 1.03-2.52]). In asymptomatic patients with severe AS and preserved ejection fraction, TAPSE <17 mm was independently predictive of mortality (adjusted HR, 2.14 [95% CI, 1.31-3.51]). Early AVR was associated with similar survival benefit in TAPSE <17 and ≥17 mm (adjusted HR, 0.23 [95% CI, 0.16-0.34] for TAPSE <17 mm, adjusted HR, 0.26 [95% CI, 0.19-0.35] for TAPSE ≥17 mm; for interaction, 0.97).

Conclusions: Right ventricular dysfunction is an important and independent predictor of mortality in AS. TAPSE <17 mm at the time of AS diagnosis is a marker of poor survival under conservative management and after AVR even in asymptomatic patients with severe AS. AVR was associated with a pronounced reduction in mortality independent of TAPSE suggesting that AVR should be discussed before right ventricular dysfunction occurs in severe AS.
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http://dx.doi.org/10.1161/CIRCIMAGING.119.009802DOI Listing
January 2020