Publications by authors named "Mario Sénéchal"

93 Publications

Effect of Acute Immunosuppression on Left Ventricular Recovery and Mortality in Fulminant Viral Myocarditis: A Case Series and Review of Literature.

CJC Open 2021 Mar 11;3(3):292-302. Epub 2020 Nov 11.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada.

Background: Fulminant viral myocarditis (FVM) is a rare cause of cardiogenic shock associated with high morbidity and mortality rates. An inappropriately activated immune system results in severe myocardial inflammation. Acute immunosuppressive therapy for FVM therefore gained in popularity and was described in numerous retrospective studies.

Methods: We conducted an extensive review of the literature and compared it with our single-centre retrospective review of all cases of FVM from 2009-2019 to evaluate the possible effect of acute immunosuppression with intravenous immunoglobulins and/or high dose corticosteroids in patients with FVM.

Results: We report on 17 patients with a mean age of 46 ± 15 years with a mean left ventricular ejection fraction (LVEF) of 15 ± 9% at admission. Fourteen (82%) of our patients had acute LVEF recovery to ≥ 45% after a mean time from immunosuppression of 74 ± 49 hours (3.1 days). Extracorporeal membrane oxygenation (ECMO) was required in 35% (6/17) of our patients for an average support of 126 ± 37 hours. Overall mortality was 12% (2/17). No patient needed a long-term left ventricular assist device or heart transplant. All surviving patients achieved complete long-term LVEF recovery.

Conclusions: Our cohort of 17 severely ill patients received acute immunosuppressive therapy and showed a rapid LVEF recovery, short duration of ECMO support, and low mortality rate. Our suggested scheme of investigation and treatment is presented. These results bring more cases of successfully treated FVM with immunosuppression and ECMO to the literature, which might stimulate further prospective trials or a registry.
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http://dx.doi.org/10.1016/j.cjco.2020.10.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985012PMC
March 2021

Non-invasive diagnostic imaging tests largely underdiagnose cardiac cirrhosis in patients undergoing advanced therapy evaluation: How can we identify the high-risk patient?

Clin Transplant 2021 Mar 7:e14277. Epub 2021 Mar 7.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Canada.

Background: Patients with liver cirrhosis are generally considered ineligible for isolated cardiac transplantation or left ventricular assist device (LVAD) implantation. The aim of this retrospective study is to explore the diagnostic value of abdominal ultrasound, computed tomography scan (CT scan) and liver-spleen scintigraphy to detect the presence of cirrhosis in patients with advanced heart failure.

Methods: Among 567 consecutive patients who underwent pre-transplantation or LVAD evaluation, 54 had a liver biopsy to rule out cardiac cirrhosis; we compared the biopsy results with the imaging investigations.

Results: In about 26% (n = 14) of patients undergoing liver biopsy, histopathological evaluation identified cirrhosis. The respective sensitivity of abdominal ultrasound, CT scan and liver-spleen scintigraphy to detect cirrhosis was 57% [29-82], 50% [16-84], and 25% [3-65]. The specificity was 80% [64-91], 89% [72-98], and 44% [20-70], respectively.

Conclusion: Ultrasonography has the best-combined sensitivity and specificity for the diagnosis of cirrhosis. However, more than a third of patients with cirrhosis will go undiagnosed by conventional imaging. As liver biopsy is associated with a low rate of complication, it should be considered in patients with a high-risk of cirrhosis or with evidence of portal hypertension to assess their eligibility for heart transplantation or LVAD implantation.
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http://dx.doi.org/10.1111/ctr.14277DOI Listing
March 2021

Annulus root enlargement during redo aortic valve replacement: Perioperative results and hemodynamic impact.

J Card Surg 2020 Sep 27;35(9):2158-2164. Epub 2020 Jul 27.

Department of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada.

Objectives: Redo aortic valve replacement (AVR) might present an increased risk for predicted patient-prosthesis mismatch (PPM). Aortic root enlargement (ARE) procedures can decrease PPM and improve hemodynamic parameters. It is crucial to evaluate the safety of ARE in the context of redo AVR to allow better patient selection.

Methods: This is a matched case-control study of 125 patients who underwent a redo AVR between 1991 and 2016, 21 patients had a concomitant ARE procedure. Patients were matched for age, gender, presence of coronary artery disease, renal clearance, left ventricular ejection fraction, and body mass index. The primary outcome was the occurrence of major adverse cardiovascular events (MACE). Secondary outcomes were postoperative impact of the ARE procedures on echocardiographic measurements and survival.

Results: Preoperatively, indexed aortic valve area (0.49 vs 0.66 cm /m ; P = .02) and left ventricle outflow tract diameters (20.1 vs 22.2 mm; P < .01) were significantly smaller in the ARE group. ARE procedures increased the aortic valve area by an average of 0.4 cm (pre = 0.9, post = 1.3; P < .01), with a reduction of maximum and mean transvalvular gradients of 26.6 mm Hg (pre = 56.8, post = 30.2; P < .01) and 17.1 mm Hg (pre = 31.9, post = 14.8; P < .01), respectively. Postoperatively, the occurrence of MACE was similar (ARE = 19%, no ARE = 14%; P = .68). Survival rates were similar (P = .29).

Conclusions: For patients undergoing redo AVR, ARE is not associated with higher perioperative mortality and morbidity when compared with patients undergoing AVR without ARE. The fear of perioperative complications potentially associated with ARE should not be a prohibiting factor in symptomatic redo patients with small aortic annulus and predicted PPM.
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http://dx.doi.org/10.1111/jocs.14726DOI Listing
September 2020

Complex drug interactions in an HIV-seropositive heart transplant recipient.

Turk Kardiyol Dern Ars 2020 03;48(2):180-184

Department of Cardiology, Institut Universitaire De Cardiologie Et De Pneumologie De Québec, Laval University, Québec, Canada.

Highly active antiretroviral therapy has led to greater life expectancy for human immun-deficiency virus (HIV)-positive patients. This was a report of 11 years of follow-up of an HIV-seropositive patient who underwent heart transplantation in 2006, with emphasis on the management challenges of complex drug interactions over time.
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http://dx.doi.org/10.5543/tkda.2019.63479DOI Listing
March 2020

Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement on Heart Transplantation: Patient Eligibility, Selection, and Post-Transplantation Care.

Can J Cardiol 2020 03;36(3):335-356

Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Université Laval, Laval, Québec, Canada.

Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recommendations were developed through systematic review of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The evolving areas of importance addressed include transplant recipient age, frailty assessment, pulmonary hypertension evaluation, cannabis use, combined heart and other solid organ transplantation, adult congenital heart disease, cardiac amyloidosis, high sensitization, and post-transplantation management of antibodies to human leukocyte antigen, rejection, cardiac allograft vasculopathy, and long-term noncardiac care. Attention is also given to Canadian-specific management strategies including the prioritization of highly sensitized transplant candidates (status 4S) and heart organ allocation algorithms. The focus topics in this position statement highlight the increased complexity of patients who undergo evaluation for heart transplantation as well as improved patient selection, and advances in post-transplantation management and surveillance that have led to better long-term outcomes for heart transplant recipients.
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http://dx.doi.org/10.1016/j.cjca.2019.12.025DOI Listing
March 2020

An unusual cause of exertional dyspnea in a 55 years old man.

Respir Med Case Rep 2020 27;29:101004. Epub 2020 Jan 27.

Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Ste-Foy Road, Quebec, QC, GIV 4G5, Canada.

A 55-year-old former professional athlete reported out of proportion dyspnea on exertion. After a detailed cardiac investigation, a cardiopulmonary exercise test on an ergocycle demonstrated an abnormal and non-physiological ventilatory response characterized by a sharp rise in ventilation followed by a decrease while exercise workload was progressively increasing. This was accompanied by noisy breathing. A laryngoscopy with direct visualisation of larynx and vocal cord during voluntary eucapnic hyperventilation confirmed the diagnosis of exercise-induced laryngeal obstruction. The patient was treated with speech therapy and all the symptoms resolved. A second cardiopulmonary exercise test showed a normalisation of the ventilatory pattern during exercise. This case demonstrates the importance of recognizing the symptoms of an exercise-induced laryngeal obstruction regardless of age, and the effectiveness of the speech therapy on symptoms and on exercise testing.
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http://dx.doi.org/10.1016/j.rmcr.2020.101004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6997562PMC
January 2020

Is heart transplantation a valuable option in patients with diffuse systemic sclerosis and primary cardiac involvement?

Clin Case Rep 2020 Jan 19;8(1):137-141. Epub 2019 Dec 19.

Department of Cardiology Institut Universitaire de Cardiologie et de Pneumologie de Québec Laval University Quebec QC Canada.

Systemic sclerosis patients with primary cardiac involvement can be reliably diagnosed by cardiac magnetic resonance imaging and are associated with a poor prognosis. This case report highlights the importance of considering heart transplantation in those patients as a lifesaving procedure.
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http://dx.doi.org/10.1002/ccr3.2600DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6982482PMC
January 2020

Usefulness of Left Ventricular Assist Device in the Recovery of Severe Amphetamine-Associated Dilated Cardiomyopathy.

Can J Cardiol 2020 02 12;36(2):317.e5-317.e7. Epub 2019 Oct 12.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada. Electronic address:

Exposure to synthetic drugs such as amphetamines may lead to significant consequences on the cardiovascular system. The prognosis of young adults with amphetamine-induced cardiomyopathy remains poor. We present 2 young patients (aged <40 years) who developed severe dilated cardiomyopathy after chronic amphetamine use. Thorough psychological evaluations demonstrated favorable features with patients being reliable and committed to their health problems. A left ventricular assist device (HeartMate II; Abbott, Chicago, IL) was implanted in the patients shortly after admission to optimize hemodynamic support and evaluate the potential for recovery. Within less than 1 year, significant improvement was achieved and successful explantation of left ventricular assist device was performed in both patients.
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http://dx.doi.org/10.1016/j.cjca.2019.09.024DOI Listing
February 2020

Do Energy Drinks Really Give You Wings? Left Ventricular Assist Device Therapy as a Bridge to Recovery for an Energy Drink-Induced Cardiomyopathy.

Can J Cardiol 2020 02 27;36(2):317.e1-317.e3. Epub 2019 Sep 27.

Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec, Canada. Electronic address:

The deleterious effect of energy drinks is increasingly recognized. We present a 26-year-old woman with inotrope-dependent severe dilated cardiomyopathy, potentially caused by chronic ingestion of energy drinks. The results of extensive investigation-consisting of cardiac magnetic resonance, F-18-fluorodesoxyglucose-positron emission tomography, coronary angiography, and endomyocardial biopsy-were normal. A left ventricular assist device (LVAD) was implanted as a potential bridge to recovery. After 10 months of mechanical support and pharmacological treatment, cardiac function was recovered, and the LVAD was successfully explanted. This is the first case report of energy drink abuse leading to severe heart failure requiring mechanical support for recovery.
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http://dx.doi.org/10.1016/j.cjca.2019.09.011DOI Listing
February 2020

Caseous Calcification of the Mitral Annulus: A Role for Surgery.

Ann Thorac Surg 2020 06 10;109(6):e441-e444. Epub 2019 Oct 10.

Service of Cardiac Surgery, Institut de cardiologie et de pneumologie de Québec (IUCPQ)-Université Laval, Quebec City, Quebec, Canada. Electronic address:

An 80-year-old man followed for aortic stenosis was found to have an intracardiac mass. Multiple imaging modalities were inconclusive in characterizing the mass but raised concerns about the potential malignancy of the mass. Fear of operating on an elderly patient with a potential for cardiac neoplasia led to a percutaneous transseptal biopsy that failed to provide a clear diagnosis. Cardiac valvular surgery was performed in addition to excisional biopsy of the mass that turned out to be caseous necrosis of mitral annular calcifications.
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http://dx.doi.org/10.1016/j.athoracsur.2019.08.110DOI Listing
June 2020

What cardiologists should know about essential thrombocythemia and acute myocardial infarction: report of two cases and advanced heart failure therapies considerations.

Int Med Case Rep J 2019 8;12:253-259. Epub 2019 Aug 8.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, QC, Canada.

We present the cases of two young male patients aged 22 and 31 without prior medical history nor cardiovascular risk factors, who presented to the hospital with large anterior ST-elevation myocardial infarction (STEMI). Urgent coronary angiography revealed acute thrombotic occlusion of the proximal left anterior descending artery in both patients. Persistent thrombocytosis was noted and subsequent investigations led to the diagnosis of essential thrombocythemia (ET) with positive JAK2-V617F mutation. Myocardial infarction as a first clinical manifestation of ET is rare but must be considered in patients without cardiovascular risk factors who show persistent thrombocytosis. In young patients without risk factors, there may be great delays before the diagnosis of STEMI is made. Longer time to revascularization of extensive STEMI is associated with adverse outcomes and cardiogenic shock which can lead to advanced therapies like heart transplant and left ventricular assist device (LVAD). Considering the favorable long-term prognosis of patients with ET, advanced therapies may be a valuable option in the presence of severe left ventricular dysfunction.
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http://dx.doi.org/10.2147/IMCRJ.S217568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6690852PMC
August 2019

Clinical and echocardiographic presentation of postmyocardial infarction papillary muscle rupture.

Echocardiography 2019 07 17;36(7):1322-1329. Epub 2019 Jun 17.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada.

Background: Severe mitral regurgitation (MR) can occur following myocardial infarction (MI) with either partial or complete papillary muscle rupture (pPMR or cPMR). Although the incidence of this complication has significantly decreased, it is still associated with significant mortality. We sought to evaluate the different echocardiographic and clinical presentations of pPMR and cPMR.

Methods And Results: A review of all the urgent procedures for ischemic MR between January 2000 and June 2016 was performed to identify patients who underwent surgery for PMR. Surgical protocols and echocardiographic studies were used to identify patients with cPMR and pPMR. A total of 37 patients had cardiac surgery for PMR (18 cPMR, 19 pPMR). All patients with cPMR were in cardiogenic shock at the time of diagnosis, as opposed to only 53% of patients with pPMR (P = 0.0008). Between the time of diagnosis and surgery, 7 patients with pPMR developed cardiogenic shock. Transthoracic echocardiography (TTE) led to the diagnosis in 72% of cPMR and 32% of pPMR (P = 0.02). TEE had a yield of 100% for both cPMR and pPMR. Six pathologic varieties of post-MI PMR were recognized on echocardiography and during surgery. Early postoperative, 1 (72% vs 84%), 3 (67% vs 84%), and 5 years (67% vs 74%) survival rates were similar for cPMR and pPMR (P = 0.26).

Conclusions: Partial PMR is associated with a different clinical and echocardiographic presentation than cPMR. Still, most pPMR patients progress toward cardiogenic shock. Prompt diagnosis and referral for surgery are critical and could potentially decrease mortality.
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http://dx.doi.org/10.1111/echo.14402DOI Listing
July 2019

Early Use of Cardiac Resynchronization Therapy to Accelerate Symptomatic Relief and Complete Left Ventricular Function Recovery in Peripartum Cardiomyopathy.

Medicina (Kaunas) 2019 Jun 5;55(6). Epub 2019 Jun 5.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Laval University, Quebec, QC G1V 0A6, Canada.

Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure that develops during the last month of pregnancy or within first months of delivery. We report the case of a 40-year-old woman diagnosed with severely symptomatic PPCM characterized by left ventricular ejection fraction (LVEF) of 10% and significant dyssynchrony secondary to a left bundle branch block (LBBB). Early cardiac resynchronization therapy (CRT) was used to achieve remarkable functional and LVEF recovery. This case suggests that early CRT must be considered for patients suffering from severely symptomatic PPCM despite optimal medical therapy for whom advanced heart failure therapies are proposed.
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http://dx.doi.org/10.3390/medicina55060246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6631786PMC
June 2019

Reply to the Letter to the Editor: Noninvasive diagnostic tools available for discrimination of pannus from thrombus in patients with prosthetic valve dysfunction.

Echocardiography 2019 06 26;36(6):1224-1225. Epub 2019 Apr 26.

Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.

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http://dx.doi.org/10.1111/echo.14347DOI Listing
June 2019

Atypical Presentation of Aspergillus Mediastinitis Infection in a Heart Transplant Patient: the Importance of Combined Medical and Surgical Treatment.

Exp Clin Transplant 2019 10 9;17(5):695-698. Epub 2019 Apr 9.

From the Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, Canada.

Aspergillus fumigatus is an opportunistic fungus that mainly affects immunocompromised patients. Due to significant immunosuppressive therapy, patients who undergo orthotopic heart transplant have an increased risk of infection. Aspergillosis is the most common fungal infection in orthotopic heart transplant recipients (70%) and usually presents as invasive aspergillosis, which has a rapidly progressive course and is highly fatal. In heart transplant patients with invasive aspergillosis, overall mortality may range from 53% to 78%. Aspergillus mediastinitis infection is somewhat rare in orthotopic heart transplant recipients, with only 6 reported cases. Treatment may require early surgical drainage and antifungal therapy. We present the case of a 50-year-old man who developed Aspergillus mediastinitis 1 year after heart transplant surgery. This case illustrates the diagnostic challenge of an atypical presentation of Aspergillus mediastinitis and the importance of multiple drainage procedures in refractory disease, combined with long-term antifungal therapy.
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http://dx.doi.org/10.6002/ect.2018.0185DOI Listing
October 2019

Prosthetic aortic valve thrombosis: To fibrinolyse or not to fibrinolyse? That is the question!

Echocardiography 2019 04 18;36(4):787-790. Epub 2019 Mar 18.

Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.

Prosthetic heart valve (PHV) dysfunction is a rare but serious complication whose optimal management may be challenging and requires a multidisciplinary approach. Treatment success ultimately depends on determining the underlying mechanism of valve dysfunction by echocardiography. However, being able to establish the main etiology is not always straightforward. We present a difficult case of obstructive PHV dysfunction and discuss clinical and echocardiographic parameters to help differentiate thrombus from pannus formation.
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http://dx.doi.org/10.1111/echo.14302DOI Listing
April 2019

What the Cardiologist Should Know About Mitochondrial Cardiomyopathy?

Can J Cardiol 2019 02 29;35(2):221-224. Epub 2018 Nov 29.

Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada. Electronic address:

Mitochondrial diseases are a heterogeneous group of rare hereditary disorders that may manifest with single organ involvement or as multisystemic disease. The pathophysiology of mitochondrial disease is complex and related to mutations of genes encoding mitochondrial proteins that are crucial to the cellular respiratory chain. Given its almost exclusive aerobic metabolism, the heart is particularly susceptible to mitochondrial dysfunction and commonly involved in mitochondrial disorders. Various clinical presentations are described, making clinical recognition challenging. Some patients may evolve towards the early need for heart transplantation, which emphasizes the importance of appropriate diagnosis and referral to a specialized centre.
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http://dx.doi.org/10.1016/j.cjca.2018.11.018DOI Listing
February 2019

Strain overestimates non-viable myocardium in patients with ischemic mitral regurgitation: understandable discrepancy of complementary methods?

J Thorac Dis 2018 Nov;10(Suppl 33):S3946-S3950

Institut Universitaire de Cardiologie et de Pneumologie de Québec - Université Laval, Québec, QC, Canada.

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http://dx.doi.org/10.21037/jtd.2018.09.69DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297517PMC
November 2018

The effect of bromocriptine on left ventricular functional recovery in peripartum cardiomyopathy: insights from the BRO-HF retrospective cohort study.

ESC Heart Fail 2019 02 22;6(1):27-36. Epub 2018 Nov 22.

Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada.

Aims: Bromocriptine is thought to facilitate left ventricular (LV) recovery in peripartum cardiomyopathy (PPCM) through inhibition of prolactin secretion. However, this potential therapeutic effect remains controversial and was incompletely studied in diverse populations.

Methods And Results: Consecutive women with new-onset PPCM (n = 76) between 1994 and 2015 in Quebec, Canada, were classified according to treatment (n = 8, 11%) vs. no treatment (n = 68, 89%) with bromocriptine. We assessed LV functional recovery at mid-term (6 months) and long-term (last follow-up) and compared outcomes among groups. Women treated with bromocriptine experienced better mid-term left ventricular ejection fraction (LVEF) recovery from 23 ± 10% at baseline to 55 ± 12% at 6 months, compared with a change from 30 ± 12% at baseline to 45 ± 13% at 6 months in women treated with standard medical therapy (P interaction < 0.01). At long-term, a similar positive association was found with bromocriptine (9% greater LVEF variation, P interaction < 0.01). In linear regressions adjusted for obstetrical, clinical, echocardiographic, and pharmacological variables, treatment with bromocriptine was associated with a greater improvement in LVEF [β coefficient (standard error), 14.1 (4.4); P = 0.03]. However, there was no significant association between bromocriptine use and the combined occurrence of all-cause death and heart failure events (hazard ratio, 1.18; 95% confidence interval, 0.15 to 9.31), using univariable Cox regressions based over a cumulative follow-up period of 285 patient-years.

Conclusions: In women newly diagnosed with PPCM, treatment with bromocriptine was independently associated with greater LV functional recovery.
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http://dx.doi.org/10.1002/ehf2.12376DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6351886PMC
February 2019

Usefulness of a titration algorithm for users of sacubitril/valsartan in a tertiary centre heart failure clinic.

Cardiovasc J Afr 2018 Nov/Dec 23;29(6):352-356. Epub 2018 Aug 28.

Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, Canada.

Background: A reduction in the rate of death and hospitalisations in patients with heart failure (HF) with reduced ejection fraction receiving sacubitril/valsartan compared to enalapril was demonstrated in the PARADIGM-HF study. However, tolerability when initiating and optimising sacubitril/valsartan treatment in real clinical practice is unknown.

Methods: We performed a prospective cohort study of clinical and biochemical parameters of the first 100 patients receiving sacubitril/valsartan in a tertiary HF clinic. Patients had titration of the molecule guided by an algorithm developed by pharmacists and cardiologists in the clinic. The objective was to evaluate the proportion of patients reaching the maximal dosage, the time to reach maximal dosage, and the rate of adverse events, as well as the required modification of other HF therapy during the sacubitril/valsartan titration.

Results: Forty-six per cent of patients reached the sacubitril/valsartan maximal dose of 97/103 mg (200 mg) twice daily and 73% received at least 49/51 mg (100 mg) twice daily. Mean titration time was 30 ± 9 days. Symptomatic hypotension, renal dysfunction (increase in creatinine level > 30%) and hyperkalaemia (potassium level > 5.5 mmol/l) occurred in nine, four and 2% of patients, respectively. Background HF pharmacological treatment remained stable during the sacubitril/valsartan titration but daily dosage of furosemide was reduced by 13% ( = 0.0005).

Conclusions: This algorithm is a safe and easy-to-use tool in daily clinical practice for the introduction and titration of sacubitril/valsartan. Almost half of the patients reached the maximal dose, with a tolerability profile in line with the original study.
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http://dx.doi.org/10.5830/CVJA-2018-039DOI Listing
December 2019

Dynamic left ventricular dyssynchrony and severe mitral regurgitation caused by exercise: should we go beyond the guidelines?

Int Med Case Rep J 2018 22;11:121-124. Epub 2018 May 22.

Department of Cardiology.

Guidelines for cardiac resynchronization therapy (CRT) have been established, but there may be a subgroup of patients not identified in these guidelines who may benefit from this therapy. We report a patient with a dynamic left ventricular dyssynchrony and severe mitral regurgitation caused by exercise successfully treated with CRT. Exercise testing should be considered in patients with left ventricular ejection fraction <35% and QRS <130 ms with severe heart failure symptoms that are unexplained by rest echocardiography evaluation in order to rule out ischemia and/or dynamic left ventricular dyssynchrony. In the presence of exercise-induced left ventricular bundle branch block, the implantation of CRT should be contemplated.
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http://dx.doi.org/10.2147/IMCRJ.S150858DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5968778PMC
May 2018

Very Late Continued Reverse Remodelling After Cardiac Resynchronization Therapy in Patients With Extreme Left Ventricular Dilatation.

Can J Cardiol 2017 06 11;33(6):831.e1-831.e3. Epub 2017 Mar 11.

Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Québec City, Québec, Canada. Electronic address:

Response to cardiac resynchronization therapy (CRT) varies greatly among patients. We present 2 patients with severe heart failure symptoms (New York Heart Association class IV) and extreme initial left ventricular (LV) dilatation (LV end-diastolic diameter of 92 mm and 80 mm, respectively) and severe functional mitral regurgitation who underwent CRT device implantation. Long-term follow-up showed late (≥ 4 years) normalization of LV ejection fraction (LVEF), LV dimensions, and functional status. In a subgroup of patients with nonischemic dilated cardiomyopathy and complete left bundle branch block, late continued LV reverse remodelling may lead to normalization of LV volumes and LVEF and significant improvement in functional class.
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http://dx.doi.org/10.1016/j.cjca.2017.02.016DOI Listing
June 2017

Clinical Presentation and Value of Echocardiography in the Diagnosis of Freestyle Aortic Bioprosthesis Leaflet Tears: A Retrospective Study.

J Heart Valve Dis 2016 09;25(5):628-633

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, Canada. Electronic correspondence:

Background: The unique design of the Freestyle stentless aortic bioprosthesis has led to different mechanisms of failure, particularly leaflet tearing. The aim of this retrospective study was to review the clinical presentation and echocardiographic data of symptomatic patients with leaflet tears and significant aortic regurgitation (AR) following implantation of the Freestyle bioprosthesis.

Methods: Between January 1993 and May 2011, a total of 430 consecutive patients was identified at the authors' institution who had undergone primary aortic valve replacement with a Freestyle stentless aortic bioprosthesis. Clinical and echocardiographic data were collected prospectively for all patients. Structural valve deterioration was the major cause of bioprosthetic valve failure.

Results: Twenty symptomatic patients presented with significant AR due to leaflet tears in the absence of more than mild valvular calcification. At presentation, all patients complained of dyspnea. Some 50% of patients (n = 10) presented with acute pulmonary edema, and 10% (n = 2) with cardiogenic shock. A leaflet tear was initially diagnosed using transthoracic echocardiography in five cases (25%), using transesophageal echocardiography (TEE) in eight cases (40%), or at surgery in seven cases (35%). An appropriate diagnosis of leaflet tearing was recognized at surgery in more than one-third of patients. Consequently, clinicians must be aware of the variety of clinical presentations and should have a high degree of suspicion regarding leaflet tears in patients who have received a Freestyle stentless aortic bioprosthesis and present with moderate to severe AR.

Conclusions: For the optimal management of patients with Freestyle stentless aortic bioprosthesis and new moderate to severe AR, TEE should be considered in all patients.
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September 2016

Prevalence and Impact of Prosthesis-Patient Mismatch Following Surgical Aortic Valve Replacement for Pure Aortic Regurgitation.

J Heart Valve Dis 2016 09;25(5):543-551

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada. Electronic correspondence:

Background: Prosthesis-patient mismatch (PPM) is highly prevalent among patients undergoing aortic valve replacement (AVR) to treat aortic stenosis. Data regarding the prevalence and impact of PPM on left ventricular remodeling and outcomes in patients who have undergone surgical AVR to treat pure severe aortic regurgitation (AR) are, however, scarce.

Methods: A retrospective analysis was conducted of clinical and echocardiographic data acquired from 50 consecutive patients with pure severe AR, without evidence of significant coronary artery disease, who underwent AVR between 2004 and 2010 at the authors' institution. PPM was defined as a projected in vivo effective orifice area (EOA) 0.85 cm2/m2.

Results: The incidence of PPM was 16%, but no severe mismatch occurred. At a mean follow up of 52 ± 39 months, event-free survival (a composite of all-cause mortality and hospitalization for cardiovascular causes) was similar between patients with and without PPM (p = 0.73). Within seven days after surgery, mean reductions in indexed left ventricular end-diastolic diameter (LVEDD) and indexed left ventricular end-systolic diameter (LVESD) were similar between patients with and without PPM [4.4 mm/m2 versus 5.0 mm/m2; p = 0.67 and 1.6 mm/m2 versus 2.2 mm/m2; p = 0.35, respectively]. At follow up, no difference was observed for mean reductions in indexed LVEDD and indexed LVESD [6.9 mm/m2 versus 7.1 mm/m2; p = 0.91 and 4.1 mm/m2 versus 5.1 mm/m2; p = 0.57, respectively], and mean improvement in left ventricular ejection fraction (4.4% versus 5.1%; p = 0.87).

Conclusions: PPM occurs less frequently in patients undergoing AVR for pure severe AR than for aortic stenosis, and seems to have a less significant impact on ventricular remodeling and outcomes.
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September 2016

Multicenter evaluation of a national organ sharing policy for highly sensitized patients listed for heart transplantation in Canada.

J Heart Lung Transplant 2017 May 6;36(5):491-498. Epub 2017 Jan 6.

Division of Cardiac Sciences, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta; Canada.

Background: Transplantation of sensitized recipients has been associated with increased risk of post-transplant complications. In 2010, the Canadian Cardiac Transplant Network (CCTN) created a unique status listing for highly sensitized heart transplant candidates. Status 4S listing requires calculated panel-reactive antibody (cPRA) level >80% as the sole listing criteria and enables geographic expansion of the donor pool by providing national access. In this study, we describe patient characteristics and outcomes of those transplanted as Status 4S in Canada.

Methods: Patients' characteristics and clinical outcomes were retrospectively collected from all 11 adult heart transplant centers in Canada.

Results: Ninety-six patients were listed Status 4S from January 2010 to September 2015. Fifty-two were transplanted as Status 4S. Of these 52 transplants, mean cPRA level was 93.4%, mean age was 47 years, 46% were male, 44% had dilated cardiomyopathy and 17% were re-transplanted for cardiac allograft vasculopathy (CAV). Blood group O comprised 42% and 53% had a left ventricular assist device as a bridge to transplant. Desensitization therapy occurred in 9 patients (17%). Over a mean follow-up period of 28 months (1 week to 5.3 years), 9 patients died (17%). Kaplan-Meier 1-year year survival is 86%. Two patients were treated for antibody-mediated rejection (AMR) in the first year post-transplant and 33% of patients had at least 1 ISHLT Grade ≥2R cellular rejection in the first year. Twenty-nine percent of patients developed de novo door-specific antibodies and demonstrated no correlation with AMR. Freedom from CAV at 1 year is 88.5% and at 5 years is 81.0%. Fifty-two percent of donor hearts originated from outside the recipients' geographic and organ donation organization.

Conclusions: A national strategy of prioritizing highly sensitized heart transplant recipients has demonstrated effective expansion of the donor pool, acceptable short-term survival, freedom from CAV and low rates of clinically relevant AMR. However, we observed significantly higher rates of cellular rejection and de novo donor-specific antibody development in this population. It is currently unknown whether this will translate into poorer long-term outcome.
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http://dx.doi.org/10.1016/j.healun.2017.01.003DOI Listing
May 2017

Canadian Cardiovascular Society/Canadian Heart Rhythm Society 2016 Implantable Cardioverter-Defibrillator Guidelines.

Can J Cardiol 2017 02 6;33(2):174-188. Epub 2016 Oct 6.

Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada.

Sudden cardiac death is a major public health issue in Canada. However, despite the overwhelming evidence to support the use of implantable cardioverter defibrillators (ICDs) in the prevention of cardiac death there remains significant variability in implantation rates across Canada. Since the most recent Canadian Cardiovascular Society position statement on ICD use in Canada in 2005, there has been a plethora of new scientific information to assist physicians in their discussions with patients considered for ICD implantation to prevent sudden cardiac death due to ventricular arrhythmias. We have reviewed, critically appraised, and synthesized the pertinent evidence to develop recommendations regarding: (1) ICD implantation in the primary and secondary prevention of sudden cardiac death in patients with and without ischemic heart disease; (2) when it is reasonable to withhold ICD implantation on the basis of comorbidities; (3) ICD implantation in patients listed for heart transplantation; (4) implantation of a single- vs dual-chamber ICD; (5) implantation of single- vs dual-coil ICD leads; (6) the role of subcutaneous ICDs; and (7) ICD implantation infection prevention strategies. We expect that this document, in combination with the companion article that addresses the implementation of these guidelines, will assist all medical professionals with the care of patients who have had or at risk of sudden cardiac death.
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http://dx.doi.org/10.1016/j.cjca.2016.09.009DOI Listing
February 2017

Usefulness of cardiac resynchronization therapy in the recovery of patients with left ventricular assist devices.

Int J Cardiol 2016 Nov 12;223:297-298. Epub 2016 Aug 12.

Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2016.08.197DOI Listing
November 2016

Echocardiographic predictors of outcomes in adults with aortic stenosis.

Heart 2016 06 5;102(12):934-42. Epub 2016 Apr 5.

Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada.

Objective: The study purpose was to assess the usefulness of echocardiographic parameters of aortic stenosis (AS) severity and left ventricular (LV) systolic function to predict mortality in AS. The main hypothesis is that parameters of LV systolic function are the most important independent predictors of mortality, whereas parameters of stenosis severity are not.

Methods: 1065 consecutive patients with AS referred to the echocardiography laboratory and meeting the inclusion/exclusion criteria were included and followed during 5.7 years. The end points were aortic valve replacement (AVR) (n=584), composite of AVR or death (n=932), all-cause mortality (n=550) and cardiovascular mortality (n=398).

Results: The most powerful echocardiographic predictors of valve-related events were parameters of AS severity, such as peak aortic jet velocity (VPeak), mean gradient (MG) and aortic valve area (AVA) (all p<0.001). Regarding mortality, the main predictors were LV ejection fraction (LVEF) and stroke volume index (SVi) (p<0.05). After multivariable adjustment, LVEF (p<0.001) and SVi (p=0.02) remained the only echocardiographic predictors of mortality, even after adjustment for symptomatic status. AVA was also associated with mortality, whereas VPeak and MG were not.

Conclusions: The most powerful echocardiographic predictors of mortality are low LVEF and low flow, whereas AS severity parameters predict valve-related events but not overall mortality. Hence, low flow should be integrated in the risk stratification and therapeutic decision-making in patients with AS.
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http://dx.doi.org/10.1136/heartjnl-2015-308742DOI Listing
June 2016

Management of Loeffler's Endocarditis With Bivalvular Involvement and a FIP1L1/PDGFRA-Negative Mutation.

Can J Cardiol 2016 12 15;32(12):1577.e9-1577.e11. Epub 2016 Jan 15.

Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Québec City, Québec, Canada.

Hypereosinophilic syndromes (HESs) are a group of disorders characterized by end-organ damage caused by eosinophilic infiltration. We present a patient with idiopathic HES with severe tricuspid and mitral regurgitation secondary to Loeffler's endocarditis. In addition to prednisone, imatinib therapy initially helped control the eosinophil count. However, successful long-term remission was achieved with hydroxyurea therapy.
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http://dx.doi.org/10.1016/j.cjca.2015.12.034DOI Listing
December 2016