Publications by authors named "Erwan Donal"

348 Publications

Natural history of functional tricuspid regurgitation: impact of cardiac output.

Eur Heart J Cardiovasc Imaging 2021 Apr 30. Epub 2021 Apr 30.

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

Aims: Tricuspid regurgitation (TR) was long forgotten until recent studies alerting on its prognostic impact. Cardiac output (CO) is the main objective of heart mechanics. We sought to compare clinical and echocardiographic data of patients with TR from inclusion to 1-year follow-up according to initial CO.

Methods And Results: Patients with isolated secondary TR and left ventricular ejection fraction (LVEF) ≥40% were prospectively included. All patients had a clinical and echocardiographic evaluation at baseline and after 1 year. Echocardiographic measurements were centralized. The patients were partitioned according to their CO at baseline. The primary outcome was all-cause death. Ninety-five patients completed their follow-up. The majority of patients had normal CO (n = 64, 67.4%), whereas 16 (16.8%) patients had low-CO and 12 (12.6%) had high-CO. right ventricular function was worse in the low-CO group but with improvement at 1 year (30% increase in tricuspid annular plane systolic excursion). LVEF and global longitudinal strain were significantly worse in the low-CO group. Overall, 18 (19%) patients died during follow-up, of which 10 (55%) patients had abnormal CO. There was a U-shaped association between CO and mortality. Normal CO patients had significantly better survival (87.5% vs. 62.5% and 66.67%) in the low- and high-CO groups, respectively, even after adjustment (heart rate 2.23 for the low-CO group and 9.08 for high-CO group; P = 0.0174).

Conclusion: Significant isolated secondary TR was associated with 19% of mortality. It is also associated with higher long-term mortality if CO is abnormal, suggesting a possible role for evaluating better and selecting patients for intervention.
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http://dx.doi.org/10.1093/ehjci/jeab070DOI Listing
April 2021

The impact of diabetes on heart failure development: the cardio-renal-metabolic connection.

Diabetes Res Clin Pract 2021 Apr 22:108831. Epub 2021 Apr 22.

Department of Cardiology, University of Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, Rennes, France.

Heart failure (HF) and chronic kidney disease (CKD) are often associated in type 2 diabetes (T2D), aggravate each other and exert synergistic effects to increase the risk of cardiac and renal events. The risks of renal worsening in HF patients and HF in CKD patients need to be evaluated to tailor preventive therapy. The recent CV and renal trials enriched our knowledge about the natural history of HF and CKD in T2D and provided evidence for the benefit of sodium-glucose cotransporter 2 inhibitors (SGLT2is) in HF and renal decline prevention. SGLT-2is are the best choice in patients with HFrEF to improve CV prognosis and HF-related outcomes and also to prevent kidney-related outcomes, and in CKD patients to slow down renal failure and also reduce hHF and CV death. In both situations the number of patients to treat in order to prevent such events in one patient is lower than in the general T2D population at high CV risk. GLP1-receptor agonists could be an alternative in a patient who is intolerant or has a contraindication to SGLT-2is. A tight collaboration between diabetologists, nephrologists and cardiologists should be encouraged for a holistic and effective strategy to reduce the burden of cardio-renal-metabolic interaction.
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http://dx.doi.org/10.1016/j.diabres.2021.108831DOI Listing
April 2021

Electrophysiological Study-Guided Permanent Pacemaker Implantation in Patients With Conduction Disturbances Following Transcatheter Aortic Valve Implantation.

Am J Cardiol 2021 Mar 20. Epub 2021 Mar 20.

Univ Rennes, CHU Rennes, Inserm, LTSI - UMR1099, F 35000 Rennes, France. Electronic address:

Conduction disturbances remain common following transcatheter aortic valve implantation (TAVI). Aside from high-degree atrioventricular block (HAVB), their optimal management remains elusive. Invasive electrophysiological studies (EPS) may help stratify patients at low or high risk of HAVB allowing for an early discharge or permanent pacemaker (PPM) implantation among patients with conduction disturbances. We evaluated the safety and diagnostic performances of an EPS-guided PPM implantation strategy among TAVI recipients with conduction disturbances not representing absolute indications for PPM. All patients who underwent TAVI at a single expert center from June 2017 to July 2020 who underwent an EPS during the index hospitalization were included in the present study. False negative outcomes were defined as patients discharged without PPM implantation who required PPM for HAVB within 6 months of the initial EPS. False positive outcomes were defined as patients discharged with a PPM with a ventricular pacing percentage <1% at follow-up. A total of 78 patients were included (median age 83.5, 39% female), among whom 35 patients (45%) received a PPM following EPS. The sensitivity, specificity, positive and negative predictive values of the EPS-guided PPM implantation strategy were 100%, 89.6%, 81.5%, and 100%, respectively. Six patients suffered a mechanical HAVB during EPS and received a PPM. These 6 patients showed PPM dependency at follow-up. In conclusion, an EPS-guided PPM implantation strategy for managing post-TAVI conduction disturbances appears effective to identify patients who can be safely discharged without PPM implantation.
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http://dx.doi.org/10.1016/j.amjcard.2021.03.014DOI Listing
March 2021

Management and outcomes of hypertrophic cardiomyopathy in young adults.

Arch Cardiovasc Dis 2021 Mar 17. Epub 2021 Mar 17.

Cardiology department, Hôpital européen Georges Pompidou, AP-HP, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; INSERM CMR970, Paris cardiovascular research centre (PARCC), 75015 Paris, France. Electronic address:

Background: Management of young adults with hypertrophic cardiomyopathy (HCM) is challenging.

Aims: To evaluate the profile of young adults (16-25 years) with HCM included in the French prospective HCM registry.

Methods: Patients were compared according to occurrence of major adverse cardiac events (MACE), comprising sudden cardiac death (SCD) events (implantable cardioverter defibrillator [ICD] discharge, SCD, sustained ventricular tachycardia), atrial fibrillation/embolic stroke, heart failure hospitalisation and unexplained syncope, at a mean follow-up of 4.4±2.2 years.

Results: At baseline, among 61 patients (20.5±3.0 years; 16 women, 26.2%), 13 (21.3%) had a prophylactic ICD, 24.6% a family history of SCD, 29.5% obstruction, 86.0% magnetic resonance imaging myocardial fibrosis, 11.8% abnormal exercise blood pressure and 52.8% a European Society of Cardiology (ESC) 5-year SCD score<4% (24.5%≥6%). At follow-up, 15 patients (24.6%; seven women; all with fibrosis) presented 17 MACE, comprising: SCD events (n=7, 41.2%; including three patients with an ICD, five with at least one SCD major classical risk factor and an ESC score≥5% and two with no risk factors and an ESC score<4%); atrial fibrillation/stroke (n=6, 35.3%); heart failure (n=1, 5.9%); syncope (n=3, 17.6%). An ICD was implanted in 11 patients (four for secondary prevention), but in only 61.5% of patients with a score≥6%. Only obstruction significantly increased MACE risk (odds ratio 3.96; P=0.035), with a non-significant trend towards a lower risk in men (OR 0.29; P=0.065).

Conclusions: In young adults with HCM, MACE are common in the short term, especially in obstructive HCM and women, mostly arrhythmic in origin. Prophylactic ICD implantation is frequent and does not strictly follow the guidelines, while the use of European/USA guidelines is helpful but imperfect in identifying SCD risk.
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http://dx.doi.org/10.1016/j.acvd.2020.12.006DOI Listing
March 2021

EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography.

Eur Heart J Cardiovasc Imaging 2021 May;22(6):e24-e57

Cardiology Department, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania.

Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.
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http://dx.doi.org/10.1093/ehjci/jeab008DOI Listing
May 2021

One year prognostic value of B-lines in dyspnoeic patients.

ESC Heart Fail 2021 Jun 11;8(3):1759-1766. Epub 2021 Mar 11.

Service de Cardiologie et Maladies Vasculaires et CIC-IT 1414, CHU Rennes, 2 rue Henri Le Guilloux, 35000, Rennes, France.

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http://dx.doi.org/10.1002/ehf2.12739DOI Listing
June 2021

Risk stratification with echocardiographic biomarkers in heart failure with preserved ejection fraction: the media echo score.

ESC Heart Fail 2021 Jun 3;8(3):1827-1839. Epub 2021 Mar 3.

Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Inserm U1116, CHRU Nancy, Université de Lorraine, and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France.

Aims: Echocardiographic predictors of outcomes in heart failure with preserved ejection fraction (HFpEF) have not been systematically or independently validated. We aimed at identifying echocardiographic predictors of cardiovascular events in a large cohort of patients with HFpEF and to validate these in an independent large cohort.

Methods And Results: We assessed the association between echocardiographic parameters and cardiovascular outcomes in 515 patients with heart failure with preserved left ventricular (LV) ejection fraction (>50%) in the MEtabolic Road to DIAstolic Heart Failure (MEDIA) multicentre study. We validated out findings in 286 patients from the Karolinska-Rennes Prospective Study of HFpEF (KaRen). After multiple adjustments including N-terminal pro-brain natriuretic peptide (NT-proBNP), the significant predictors of death or cardiovascular hospitalization were pulmonary arterial systolic pressure > 40 mmHg, respiratory variation in inferior vena cava diameter > 0.5, E/e' > 9, and lateral mitral annular s' < 7 cm/s. The combination of these four variables differentiated patients with <10% vs. >35% 1 year risk. Adding these four echocardiographic variables on top of clinical variables and NT-proBNP yielded significant net reclassification improvement (33.8%, P < 0.0001) and increase in C-index (5.3%, a change from 72.2% to 77.5%, P = 0.015) of similar magnitude as the addition of NT-proBNP on top of clinical variables alone. In the KaRen cohort, these four variables yielded a similar improvement in net reclassification improvement (22.3%, P = 0.014) and C-index (4.0%, P = 0.029).

Conclusions: Use of four simple echocardiographic parameters (within the MEDIA echo score), indicative of pulmonary hypertension, elevated central venous pressure, LV diastolic dysfunction, and LV long-axis systolic dysfunction, independently predicted prognosis and improved risk stratification additionally to clinical variables and NT-proBNP in HFpEF. This finding was validated in an independent cohort.
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http://dx.doi.org/10.1002/ehf2.13251DOI Listing
June 2021

The structural heart disease interventional imager rationale, skills and training: a position paper of the European Association of Cardiovascular Imaging.

Eur Heart J Cardiovasc Imaging 2021 Apr;22(5):471-479

Dept of Cardiology, Oslo University Hospital, Pb 4950 Nydalen, 0424, Oslo, Norway.

Percutaneous therapeutic options for an increasing variety of structural heart diseases (SHD) have grown dramatically. Within this context of continuous expansion of devices and procedures, there has been increased demand for physicians with specific knowledge, skills, and advanced training in multimodality cardiac imaging. As a consequence, a new subspecialty of 'Interventional Imaging' for SHD interventions and a new dedicated professional figure, the 'Interventional Imager' with specific competencies has emerged. The interventional imager is an integral part of the heart team and plays a central role in decision-making throughout the patient pathway, including the appropriateness and feasibility of a procedure, pre-procedural planning, intra-procedural guidance, and post-procedural follow-up. However, inherent challenges exist to develop a training programme for SHD imaging that differs from traditional cardiovascular imaging pathways. The purpose of this document is to provide the standard requirements for the training in SHD imaging, as well as a starting point for an official certification process for SHD interventional imager.
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http://dx.doi.org/10.1093/ehjci/jeab005DOI Listing
April 2021

Optimized Implementation of cardiac resynchronization therapy - a call for action for referral and optimization of care.

Europace 2021 Feb 5. Epub 2021 Feb 5.

Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.

Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heartfailure hospitalization rates and reduces all-cause mortality. Nevertheless, up to two-thirds ofeligible patients are not referred for CRT. Furthermore, post implantation follow-up is oftenfragmented and suboptimal, hampering the potential maximal treatment effect. This jointposition statement from three ESC Associations, HFA, EHRA and EACVI focuses onoptimized implementation of CRT. We offer theoretical and practical strategies to achievemore comprehensive CRT referral and post-procedural care by focusing on four actionabledomains; (I) overcoming CRT under-utilization, (II) better understanding of pre-implantcharacteristics, (III) abandoning the term 'non-response' and replacing this by the concept ofdisease modification, and (IV) implementing a dedicated post-implant CRT care pathway.
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http://dx.doi.org/10.1093/europace/euab035DOI Listing
February 2021

Characterization of Responder Profiles for Cardiac Resynchronization Therapy through Unsupervised Clustering of Clinical and Strain Data.

J Am Soc Echocardiogr 2021 May 29;34(5):483-493. Epub 2021 Jan 29.

Université de Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France. Electronic address:

Background: The mechanisms of improvement of left ventricular (LV) function with cardiac resynchronization therapy (CRT) are not yet elucidated. The aim of this study was to characterize CRT responder profiles through clustering analysis, on the basis of clinical and echocardiographic preimplantation data, integrating automatic quantification of longitudinal strain signals.

Methods: This was a multicenter observational study of 250 patients with chronic heart failure evaluated before CRT device implantation and followed up to 4 years. Clinical, electrocardiographic, and echocardiographic data were collected. Regional longitudinal strain signals were also analyzed with custom-made algorithms in addition to existing approaches, including myocardial work indices. Response was defined as a decrease of ≥15% in LV end-systolic volume. Death and hospitalization for heart failure at 4 years were considered adverse events. Seventy features were analyzed using a clustering approach (k-means clustering).

Results: Five clusters were identified, with response rates between 50% in cluster 1 and 92.7% in cluster 5. These five clusters differed mainly by the characteristics of LV mechanics, evaluated using strain integrals. There was a significant difference in event-free survival at 4 years between cluster 1 and the other clusters. The quantitative analysis of strain curves, especially in the lateral wall, was more discriminative than apical rocking, septal flash, or myocardial work in most phenogroups.

Conclusions: Five clusters are described, defining groups of below-average to excellent responders to CRT. These clusters demonstrate the complexity of LV mechanics and prediction of response to CRT. Automatic quantitative analysis of longitudinal strain curves appears to be a promising tool to improve the understanding of LV mechanics, patient characterization, and selection for CRT.
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http://dx.doi.org/10.1016/j.echo.2021.01.019DOI Listing
May 2021

Left ventricular strain for predicting the response to cardiac resynchronization therapy: two methods for one question.

Eur Heart J Cardiovasc Imaging 2021 Jan 31. Epub 2021 Jan 31.

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

Aims: Myocardial work (manually controlled software) and integral-derived longitudinal strain (automatic quantification of strain curves) are two promising tools to quantify dyssynchrony and potentially select the patients that are most likely to have a reverse remodelling due to cardiac resynchronization therapy (CRT). We sought to test and compare the value of these two methods in the prediction of CRT-response.

Materials And Results: Two hundred and forty-three patients undergoing CRT-implantation from three European referral centres were considered. The characteristics from the six-segment of the four-chamber view were computed to obtain regional myocardial work and the automatically generated integrals of strain. The characteristics were studied in mono-parametric and multiparametric evaluations to predict CRT-induced 6-month reverse remodelling. For each characteristic, the performance to estimate the CRT response was determined with the receiver operating characteristic (ROC) curve and the difference between the performances was statistically evaluated. The best area under the curve (AUC) when only one characteristic used was obtained for a myocardial work (AUC = 0.73) and the ROC curve was significantly better than the others. The best AUC for the integrals was 0.63, and the ROC curve was not significantly greater than the others. However, with the best combination of works and integrals, the ROC curves were not significantly different and the AUCs were 0.77 and 0.72.

Conclusion: Myocardial work used in a mono-parametric estimation of the CRT-response has better performance compared to other methods. However, in a multiparametric application such as what could be done in a machine-learning approach, the two methods provide similar results.
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http://dx.doi.org/10.1093/ehjci/jeaa422DOI Listing
January 2021

The future of the diastolic function assessment will take advantage of the past and of the automatization.

Eur Heart J Cardiovasc Imaging 2021 Apr;22(5):599-600

Univ Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, F-35033 Rennes, France.

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http://dx.doi.org/10.1093/ehjci/jeab014DOI Listing
April 2021

Are We Right to Believe in the Value of Transcatheter Treatment of Secondary Tricuspid Regurgitation?

J Am Coll Cardiol 2021 Jan;77(3):240-242

Cardiology Department, Bichat Hospital, AP-HP, Université de Paris, Paris, France.

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http://dx.doi.org/10.1016/j.jacc.2020.11.037DOI Listing
January 2021

Cardiac remodelling in secondary tricuspid regurgitation: Should we look beyond the tricuspid annulus diameter?

Arch Cardiovasc Dis 2021 Jan 11. Epub 2021 Jan 11.

Université de Rennes 1, 35043 Rennes, France; Department of Cardiology, CHU Rennes, 35000 Rennes, France. Electronic address:

Background: A better understanding of the mechanism of tricuspid regurgitation severity would help to improve the management of this disease.

Aim: We sought to characterize the determinants of isolated secondary tricuspid regurgitation severity in patients with preserved left ventricular ejection fraction.

Methods: This was a prospective observational multicentre study. Patients with severe tricuspid regurgitation were asked to participate in a registry that required a control echocardiogram after optimization of medical treatment and a follow-up. Patients had to have at least mild secondary tricuspid regurgitation when clinically stable, and were classified according to five grades of tricuspid regurgitation severity, based on effective regurgitant orifice area.

Results: One hundred patients with tricuspid regurgitation (12 mild, 31 moderate, 18 severe, 17 massive and 22 torrential) were enrolled. Right atrial indexed volume and tethering area were statistically associated with the degree of tricuspid regurgitation (P<0.001 and P=0.005, respectively). When the tricuspid annular diameter was≥50mm, the probability of having severe tricuspid regurgitation or a higher grade was>70%. For an increase of 10mL/m in right atrial volume, the effective regurgitant orifice area increased by 4.2mm, and for an increase of 0.1cm in the tethering area, the effective regurgitant orifice area increased by 2.35mm. The degree of right ventricular dilation and changes in tricuspid morphology were significantly related to tricuspid regurgitation severity class (P<0.001). No significant difference in right ventricular function variables was observed between the tricuspid regurgitation classes.

Conclusions: For tricuspid regurgitation to be severe or torrential, both right atrial dilatation and leaflet tethering are needed. Interestingly, right cavities dilated progressively with tricuspid regurgitation severity, without joint degradation of right ventricular systolic function variables.
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http://dx.doi.org/10.1016/j.acvd.2020.11.002DOI Listing
January 2021

Artificial intelligence and the promise of uplifting echocardiography.

Heart 2021 Jan 12. Epub 2021 Jan 12.

School of Medicine and Surgery, University of Milan-Bicocca, Milano, Italy.

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http://dx.doi.org/10.1136/heartjnl-2020-318718DOI Listing
January 2021

Importance of Systematic Right Ventricular Assessment in Cardiac Resynchronization Therapy Candidates: A Machine Learning Approach.

J Am Soc Echocardiogr 2021 May 7;34(5):494-502. Epub 2021 Jan 7.

Université de Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France. Electronic address:

Background: Despite all having systolic heart failure and broad QRS intervals, patients screened for cardiac resynchronization therapy (CRT) are highly heterogeneous, and it remains extremely challenging to predict the impact of CRT devices on left ventricular function and outcomes. The aim of this study was to evaluate the relative impact of clinical, electrocardiographic, and echocardiographic data on the left ventricular remodeling and prognosis of CRT candidates by the application of machine learning approaches.

Methods: One hundred ninety-three patients with systolic heart failure receiving CRT according to current recommendations were prospectively included in this multicenter study. A combination of the Boruta algorithm and random forest methods was used to identify features predicting both CRT volumetric response and prognosis. Model performance was tested using the area under the receiver operating characteristic curve. The k-medoid method was also applied to identify clusters of phenotypically similar patients.

Results: From 28 clinical, electrocardiographic, and echocardiographic variables, 16 features were predictive of CRT response, and 11 features were predictive of prognosis. Among the predictors of CRT response, eight variables (50%) pertained to right ventricular size or function. Tricuspid annular plane systolic excursion was the main feature associated with prognosis. The selected features were associated with particularly good prediction of both CRT response (area under the curve, 0.81; 95% CI, 0.74-0.87) and outcomes (area under the curve, 0.84; 95% CI, 0.75-0.93). An unsupervised machine learning approach allowed the identification of two phenogroups of patients who differed significantly in clinical variables and parameters of biventricular size and right ventricular function. The two phenogroups had significantly different prognosis (hazard ratio, 4.70; 95% CI, 2.1-10.0; P < .0001; log-rank P < .0001).

Conclusions: Machine learning can reliably identify clinical and echocardiographic features associated with CRT response and prognosis. The evaluation of both right ventricular size and functional parameters has pivotal importance for the risk stratification of CRT candidates and should be systematically performed in patients undergoing CRT.
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http://dx.doi.org/10.1016/j.echo.2020.12.025DOI Listing
May 2021

Prediction of AF in Heart Failure With Preserved Ejection Fraction: Incremental Value of Left Atrial Strain.

JACC Cardiovasc Imaging 2021 Jan;14(1):131-144

Wroclaw Medical University, Wroclaw, Poland; Baker Heart and Diabetes Institute, Melbourne, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.

Objectives: This study sought to identify the factors associated with incident atrial fibrillation (AF) in a well-characterized heart failure with preserved ejection fraction (HFpEF) population, with special focus on left atrial (LA) strain.

Background: AF is associated with HFpEF, with adverse consequences. Effective risk evaluation might allow the initiation of protective strategies.

Methods: Clinical evaluation and echocardiography, including measurements of peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and LA volume index (LAVI), were obtained in 170 patients with symptomatic HFpEF (mean age, 65 ± 8 years), free of baseline AF. AF was identified by standard 12-lead electrocardiogram, review of relevant medical records (including Holter documentation), and surveillance with a portable single-lead electrocardiogram device over 2 weeks. Results were validated in the 103 patients with HFpEF from the Karolinska-Rennes (KaRen) study.

Results: Over a median follow-up of 49 months, incident AF was identified in 39 patients (23%). Patients who developed AF were older; had higher clinical risk scores, brain natriuretic peptide, creatinine, LAVI, and LV mass; lower LA strain and exercise capacity; and more impaired LV diastolic function. PACS, PALS, and LAVI were the most predictive parameters for AF (area under receiver-operating characteristic curve: 0.76 for PACS, 0.71 for PALS, and 0.72 for LAVI). Nested Cox regression models showed that the predictive value of PACS and PALS was independent from and incremental to clinical data, LAVI, and E/e' ratio. Classification and regression trees analysis identified PACS ≤12.7%, PALS ≤29.4%, and LAVI >34.3 ml/m as discriminatory nodes for AF, with a 33-fold greater hazard of AF (p < 0.001) in patients categorized as high risk. The classification and regression trees algorithm discriminated high and low AF risk in the validation cohort.

Conclusions: PACS and PALS provide incremental predictive information about incident AF in HFpEF. The inclusion of these LA strain components to the diagnostic algorithm may help guide screening and further monitoring for AF risk in this population.
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http://dx.doi.org/10.1016/j.jcmg.2020.07.040DOI Listing
January 2021

Is It Fair to Use the Current Estimation of Myocardial Work in Patients with Significant Aortic Stenosis?

J Am Soc Echocardiogr 2021 Apr 7;34(4):451. Epub 2021 Jan 7.

Université Rennes, Department of Cardiology, CHU Rennes, Inserm, LTSI-UMR 1099, Rennes, France.

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http://dx.doi.org/10.1016/j.echo.2020.11.010DOI Listing
April 2021

Percutaneous Treatment of Mitral Regurgitation With the PASCAL Device: A Full Grasp of the Pathology?

JACC Cardiovasc Interv 2020 12;13(23):2779-2781

Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France; CHU Rennes, Service de Cardiologie, Rennes, France.

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http://dx.doi.org/10.1016/j.jcin.2020.09.057DOI Listing
December 2020

How to measure left ventricular myocardial work by pressure-strain loops.

Eur Heart J Cardiovasc Imaging 2021 Feb;22(3):259-261

Institute for Surgical Research and Department of Cardiology, Oslo University Hospital and University of Oslo, Rikshospitalet, N-0027 Oslo, Norway.

Myocardial work is calculated from non-invasive left ventricular pressure and strain by speckle tracking echocardiography. Myocardial work provides diagnostic information beyond what is achieved from left ventricular ejection fraction and strain since it incorporates afterload, and provides a measure of myocardial efficiency. The method can be used to calculate global as well as segmental work. The work method was recently shown to be of clinical value in selection of patients for cardiac resynchronization therapy. Several other clinical applications are currently tested.
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http://dx.doi.org/10.1093/ehjci/jeaa301DOI Listing
February 2021

Training, competence, and quality improvement in echocardiography: the European Association of Cardiovascular Imaging Recommendations: update 2020.

Eur Heart J Cardiovasc Imaging 2020 12;21(12):1305-1319

Department of Cardiology, Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway.

The primary mission of the European Association of Cardiovascular Imaging (EACVI) is 'to promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular imaging'. Echocardiography is a key component in the evaluation of patients with known or suspected cardiovascular disease and is essential for the high quality and effective practice of clinical cardiology. The EACVI aims to update the previously published recommendations for training, competence, and quality improvement in echocardiography since these activities are increasingly recognized by patients, physicians, and payers. The purpose of this document is to provide the general requirements for training and competence in echocardiography, to outline the principles of quality evaluation, and to recommend a set of measures for improvement, with the ultimate goal of raising the standards of echocardiographic practice. Moreover, the document aims to provide specific guidance for advanced echo techniques, which have dramatically evolved since the previous publication in 2009.
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http://dx.doi.org/10.1093/ehjci/jeaa266DOI Listing
December 2020

New expectations for diastolic function assessment in transthoracic echocardiography based on a semi-automated computing of strain-volume loops.

Eur Heart J Cardiovasc Imaging 2020 12;21(12):1366-1371

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

Aims: Early diagnosis of heart failure with preserved ejection fraction (HFpEF) by determination of diastolic dysfunction is challenging. Strain-volume loop (SVL) is a new tool to analyse left ventricular function. We propose a new semi-automated method to calculate SVL area and explore the added value of this index for diastolic function assessment.

Method And Results: Fifty patients (25 amyloidosis, 25 HFpEF) were included in the study and compared with 25 healthy control subjects. Left ventricular ejection fraction was preserved and similar between groups. Classical indices of diastolic function were pathological in HFpEF and amyloidosis groups with greater left atrial volume index, greater mitral average E/e' ratio, faster tricuspid regurgitation (P < 0.0001 compared with controls). SVL analysis demonstrated a significant difference of the global area between groups, with the smaller area in amyloidosis group, the greater in controls and a mid-range value in HFpEF group (37 vs. 120 vs. 72 mL.%, respectively, P < 0.0001). Applying a linear discriminant analysis (LDA) classifier, results show a mean area under the curve of 0.91 for the comparison between HFpEF and amyloidosis groups.

Conclusion: SVLs area is efficient to identify patients with a diastolic dysfunction. This new semi-automated tool is very promising for future development of automated diagnosis with machine-learning algorithms.
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http://dx.doi.org/10.1093/ehjci/jeaa123DOI Listing
December 2020

Prediction of response to cardiac resynchronization therapy using a multi-feature learning method.

Int J Cardiovasc Imaging 2021 Mar 23;37(3):989-998. Epub 2020 Nov 23.

Univ Rennes, CHU Rennes, Inserm, LTSI UMR 1099, 35000, Rennes, France.

We hypothesized that a multiparametric evaluation, based on the combination of electrocardiographic and echocardiographic parameters, could enhance the appraisal of the likelihood of reverse remodeling and prognosis of favorable clinical evolution to improve the response of cardiac resynchronization therapy (CRT). Three hundred and twenty-three heart failure patients were retrospectively included in this multicenter study. 221 patients (68%) were responders, defined by a decrease in left ventricle end-systolic volume ≥15% at the 6-month follow-up. In addition, strain data coming from echocardiography were analyzed with custom-made signal processing methods. Integrals of regional longitudinal strain signals from the beginning of the cardiac cycle to strain peak and to the instant of aortic valve closure were analyzed. QRS duration, septal flash and different other features manually extracted were also included in the analysis. The random forest (RF) method was applied to analyze the relative feature importance, to select the most significant features and to build an ensemble classifier with the objective of predicting response to CRT. The set of most significant features was composed of Septal Flash, E, E/A, E/EA, QRS, left ventricular end-diastolic volume and eight features extracted from strain curves. A Monte Carlo cross-validation method with 100 runs was applied, using, in each run, different random sets of 80% of patients for training and 20% for testing. Results show a mean area under the curve (AUC) of 0.809 with a standard deviation of 0.05. A multiparametric approach using a combination of echo-based parameters of left ventricular dyssynchrony and QRS duration helped to improve the prediction of the response to cardiac resynchronization therapy.
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http://dx.doi.org/10.1007/s10554-020-02083-1DOI Listing
March 2021

Haemodynamic evaluation: a key tool for heart failure management. Ultrasounds forever!

Eur J Heart Fail 2020 Nov 20. Epub 2020 Nov 20.

Department of Cardiology, University of Baskent, Ankara, Turkey.

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http://dx.doi.org/10.1002/ejhf.2055DOI Listing
November 2020

Multicentric Atrial Strain COmparison between Two Different Modalities: MASCOT HIT Study.

Diagnostics (Basel) 2020 Nov 13;10(11). Epub 2020 Nov 13.

Department "Gailezers", Riga East Clinical University Hospital, LV-1038 Riga, Latvia.

Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume-pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference.
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http://dx.doi.org/10.3390/diagnostics10110946DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7696899PMC
November 2020

Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: A joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology.

Eur J Heart Fail 2020 12;22(12):2349-2369

Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France.

Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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http://dx.doi.org/10.1002/ejhf.2046DOI Listing
December 2020

Mechanical dyssynchrony is better understood and it might be a good news for heart failure patients.

Eur Heart J Cardiovasc Imaging 2021 Jan;22(1):46-48

Service de Cardiologie - Hôpital Pontchaillou, CHU de Rennes, LTSI, Inserm 1099, Rennes 35000, France.

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http://dx.doi.org/10.1093/ehjci/jeaa216DOI Listing
January 2021

Reproducibility of reading echocardiographic parameters to assess severity of mitral regurgitation. Insights from a French multicentre study.

Arch Cardiovasc Dis 2020 Oct 29;113(10):599-606. Epub 2020 Sep 29.

Department of Cardiology and Heart Valve Center, University Hospital of Rangueil, Toulouse 31400, France.

Background: Poor reproducibility in assessment of mitral regurgitation (MR) has been reported.

Aim: To investigate the robustness of echocardiographic MR assessment in 2019, based on improvements in technology and the skill of echocardiographists regarding MR quantification.

Methods: Reproducibility in parameters of MR severity and global rating were tested using transthoracic echocardiography in 25 consecutive patients independently analysed by 16 junior and senior cardiologists specialized in echocardiography (400 analyses per parameter).

Results: Overall interobserver agreement for mechanism definition, effective regurgitant orifice area (EROA) and regurgitant volume (RVol) was moderate, and was lower in secondary MR. Interobserver agreement was substantial for EROA [0.61, 95% confidence interval (CI) 0.45-0.75] and moderate for RVol with the PISA method (0.50, 95% CI 0.33-0.56) in senior physicians and was fair in junior physicians (0.33, 95% CI 0.19-0.51 and 0.36, 95% CI 0.36-0.43, respectively). Using a multiparametric approach, overall interobserver agreement for grading MR severity was fair (0.30), was slightly better in senior than in junior physicians (0.31 vs. 0.28, respectively) with substantial or almost perfect agreement more frequently observed in senior versus junior physicians (52% vs. 36%, respectively).

Conclusion: Reproducible transthoracic echocardiography MR quantification remains challenging in 2019, despite the expected high skills of echocardiographers regarding MR at the time of dedicated percutaneous intervention. The multiparametric approach does not entirely alleviate the substantial dispersion in measurement of MR severity parameters, whereas reader experience seems to partially address the issue. Our study emphasizes the continuing need for multimodality imaging and education in the evaluation of MR among cardiologists.
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http://dx.doi.org/10.1016/j.acvd.2020.02.004DOI 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