Publications by authors named "Mohammed Nejjari"

19 Publications

  • Page 1 of 1

ST-Segment Elevation Myocardial Infarction Following Transcatheter Aortic Valve Replacement.

J Am Coll Cardiol 2021 May;77(17):2187-2199

Hospital Universitario Ramón y Cajal, Madrid, Spain.

Background: Among patients with acute coronary syndrome following transcatheter aortic valve replacement (TAVR), those presenting with ST-segment elevation myocardial infarction (STEMI) are at highest risk.

Objectives: The goal of this study was to determine the clinical characteristics, management, and outcomes of STEMI after TAVR.

Methods: This was a multicenter study including 118 patients presenting with STEMI at a median of 255 days (interquartile range: 9 to 680 days) after TAVR. Procedural features of STEMI after TAVR managed with primary percutaneous coronary intervention (PCI) were compared with all-comer STEMI: 439 non-TAVR patients who had primary PCI within the 2 weeks before and after each post-TAVR STEMI case in 5 participating centers from different countries.

Results: Median door-to-balloon time was higher in TAVR patients (40 min [interquartile range: 25 to 57 min] vs. 30 min [interquartile range: 25 to 35 min]; p = 0.003). Procedural time, fluoroscopy time, dose-area product, and contrast volume were also higher in TAVR patients (p < 0.01 for all). PCI failure occurred more frequently in patients with previous TAVR (16.5% vs. 3.9%; p < 0.001), including 5 patients in whom the culprit lesion was not revascularized owing to coronary ostia cannulation failure. In-hospital and late (median of 7 months [interquartile range: 1 to 21 months]) mortality rates were 25.4% and 42.4%, respectively (20.6% and 38.2% in primary PCI patients), and estimated glomerular filtration rate <60 ml/min (hazard ratio [HR]: 3.02; 95% confidence interval [CI]: 1.42 to 6.43; p = 0.004), Killip class ≥2 (HR: 2.74; 95% CI: 1.37 to 5.49; p = 0.004), and PCI failure (HR: 3.23; 95% CI: 1.42 to 7.31; p = 0.005) determined an increased risk.

Conclusions: STEMI after TAVR was associated with very high in-hospital and mid-term mortality. Longer door-to-balloon times and a higher PCI failure rate were observed in TAVR patients, partially due to coronary access issues specific to the TAVR population, and this was associated with poorer outcomes.
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http://dx.doi.org/10.1016/j.jacc.2021.03.014DOI Listing
May 2021

Case report: takotsubo cardiomyopathy after transcatheter aortic valve-in-valve replacement.

Eur Heart J Case Rep 2021 Jan 20;5(1):ytaa457. Epub 2020 Dec 20.

Centre Cardiologique du Nord, 32-36 Rue des Moulins Gémeaux, 93200 Saint-Denis, France.

Background : Transcatheter aortic valve implantation (TAVI) has become a first-line therapeutic option in patients with severe, symptomatic aortic stenosis at increased surgical risk. Despite its success, the TAVI procedure has been associated with acute life-threatening complications as myocardial infarction secondary to periprocedural coronary occlusion, annular rupture, or vascular injury.

Case Summary : A 79-year-old woman with a dysfunctional bioprosthetic valve following previous surgical valve replacement was hospitalized in our institution to perform a Valve-in-Valve Transcatheter Aortic Valve Replacement (ViV TAVR). Shortly after the implantation of an Evolut R valve (without complication), left ventricle dysfunction with apical akinesia and basal hyperkinesia was identified during bedside transthoracic echocardiography, in spite of a good prosthesis implantation and function. A concomitant Troponin elevation was noted, and the day-after resting electrocardiogram showed a lateral T-wave inversion. Coronary computed tomography angiography showed no coronary stenosis or occlusion, cardiac magnetic resonance imaging showed no necrosis or fibrosis, and no argument for myocarditis. The patient remained asymptomatic during her hospital stay, and the aforementioned anomalies spontaneously regressed after an in-hospital 2-week surveillance. In the presence of these transient anomalies and after ruling out myocardial infarction and myocarditis, post-procedural stress cardiomyopathy (takotsubo) was diagnosed.

Discussion : Post-TAVR stress-related cardiomyopathy seems to be an extremely rare entity. To our knowledge, this is the first case of a takotsubo cardiomyopathy after ViV TAVR. Though the association between the two seems likely to be causal, no clear physiopathological explanation can be formulated.
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http://dx.doi.org/10.1093/ehjcr/ytaa457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898568PMC
January 2021

Chimney Stenting for Coronary Occlusion During TAVR: Insights From the Chimney Registry.

JACC Cardiovasc Interv 2020 03;13(6):751-761

Institut Cardiovasculaire de Paris, Massy, France.

Objectives: The aim of this study was to determine the safety and efficacy of chimney stenting, a bailout technique to treat coronary artery occlusion (CAO).

Background: CAO during transcatheter aortic valve replacement (TAVR) is a rare but often fatal complication.

Methods: In the international Chimney Registry, patient and procedural characteristics and data on outcomes are retrospectively collected from patients who underwent chimney stenting during TAVR.

Results: To date, 16 centers have contributed 60 cases among 12,800 TAVR procedures (0.5%). Chimney stenting was performed for 2 reasons: 1) due to the development of an established CAO (n = 25 [41.6%]); or 2) due to an impending CAO (n = 35 [58.3%]). The majority of cases (92.9%) had 1 or more classical risk factors for CAO. Upfront coronary protection was performed in 44 patients (73.3%). Procedural and in-hospital mortality occurred in 1 and 2 patients, respectively. Myocardial infarction (52.0% vs. 0.0%; p < 0.01), cardiogenic shock (52.0% vs. 2.9%; p < 0.01), and resuscitation (44.0% vs. 2.9%; p < 0.01) all occurred more frequently in patients with established CAO compared with those with impending CAO. The absence of upfront coronary protection was the sole independent risk factor for the combined endpoint of death, cardiogenic shock, or myocardial infarction. During a median follow-up time of 612 days (interquartile range: 405 to 842 days), 2 cases of stent failure were reported (1 in-stent restenosis, 1 possible late stent thrombosis) after 157 and 374 days.

Conclusions: Chimney stenting appears to be an acceptable bailout technique for CAO, with higher event rates among those with established CAO and among those without upfront coronary protection.
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http://dx.doi.org/10.1016/j.jcin.2020.01.227DOI Listing
March 2020

Percutaneous repair or medical treatment for secondary mitral regurgitation: outcomes at 2 years.

Eur J Heart Fail 2019 12 18;21(12):1619-1627. Epub 2019 Nov 18.

Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS, UMR5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Service de Biostatistique - Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Villeurbanne, France.

Aims: The MITRA-FR trial showed that among symptomatic patients with severe secondary mitral regurgitation, percutaneous repair did not reduce the risk of death or hospitalization for heart failure at 12 months compared with guideline-directed medical treatment alone. We report the 24-month outcome from this trial.

Methods And Results: At 37 centres, we randomly assigned 304 symptomatic heart failure patients with severe secondary mitral regurgitation (effective regurgitant orifice area >20 mm or regurgitant volume >30 mL), and left ventricular ejection fraction between 15% and 40% to undergo percutaneous valve repair plus medical treatment (intervention group, n = 152) or medical treatment alone (control group, n = 152). The primary efficacy outcome was the composite of all-cause death and unplanned hospitalization for heart failure at 12 months. At 24 months, all-cause death and unplanned hospitalization for heart failure occurred in 63.8% of patients (97/152) in the intervention group and 67.1% (102/152) in the control group [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.77-1.34]. All-cause mortality occurred in 34.9% of patients (53/152) in the intervention group and 34.2% (52/152) in the control group (HR 1.02, 95% CI 0.70-1.50). Unplanned hospitalization for heart failure occurred in 55.9% of patients (85/152) in the intervention group and 61.8% (94/152) in the control group (HR 0.97, 95% CI 0.72-1.30).

Conclusions: In patients with severe secondary mitral regurgitation, percutaneous repair added to medical treatment did not significantly reduce the risk of death or hospitalization for heart failure at 2 years compared with medical treatment alone.
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http://dx.doi.org/10.1002/ejhf.1616DOI Listing
December 2019

The Choice of Treatment in Ischemic Mitral Regurgitation With Reduced Left Ventricular Function.

Ann Thorac Surg 2019 12 22;108(6):1901-1912. Epub 2019 Aug 22.

Department of Surgery and Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York.

Background: Ischemic mitral regurgitation is a condition characterized by mitral insufficiency secondary to an ischemic left ventricle. Primarily, the pathology is the result of perturbation of normal regional left ventricular geometry combined with adverse remodeling. We present a comprehensive review of contemporary surgical, medical, and percutaneous treatment options for ischemic mitral regurgitation, rigorously examined by current guidelines and literature.

Methods: We conducted a literature search of the PubMed database, Embase, and the Cochrane Library (through November 2018) for studies reporting perioperative or late mortality and echocardiographic outcomes after surgical and nonsurgical intervention for ischemic mitral regurgitation.

Results: Treatment of this condition is challenging and often requires a multimodality approach. These patients usually have multiple comorbidities that may preclude surgery as a viable option. A multidisciplinary team discussion is crucial in optimizing outcomes. There are several options for treatment and management of ischemic mitral regurgitation with differing benefits and risks. Guideline-directed medical therapy for heart failure is the treatment choice for moderate and severe ischemic mitral regurgitation, with consideration of coronary revascularization, mitral valve surgery, cardiac resynchronization therapy, or a combination of these, in appropriate candidates. The use of transcatheter mitral valve therapy is considered appropriate in high-risk patients with severe ischemic mitral regurgitation, heart failure, and reduced left ventricular ejection fraction, especially in those with hemodynamic instability.

Conclusions: The role of mitral valve surgery and transcatheter mitral valve therapy continues to evolve.
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http://dx.doi.org/10.1016/j.athoracsur.2019.06.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424599PMC
December 2019

Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation.

N Engl J Med 2018 12 27;379(24):2297-2306. Epub 2018 Aug 27.

From Hopital Cardiovasculaire Louis Pradel, Chirurgie Cardio-Vasculaire et Transplantation Cardiaque (J.-F.O.), Pharmacy Department and Laboratoire Mateis (X.A.), and Hopital Cardiovasculaire Louis Pradel, Clinical Investigation Center and Heart Failure Department, INSERM 1407 (C.B., G.S., N. Mewton), Hospices Civils de Lyon and Claude Bernard University, Lyon, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Bichat (D.M.-Z., B.I., A.V.), and APHP, Hôpital Européen Georges Pompidou (N.K.), Paris, Centre Hospitalier Universitaire (CHU) Rennes, Hôpital Pontchaillou, Rennes (G.L., E.D.), Assistance Publique-Hôpitaux de Marseille (APHM), Hôpital de la Timone (G.B.), and Hôpital Saint Joseph (N. Michel), Marseille, CHU Nantes, Hôpital Guillaume et René Laennec, Nantes (N.P., J.-N.T., P.G.), Institut Jacques Cartier, Massy (T.L., B.C.), Clinique du Millénaire (C.P.) and CHU Montpellier, Hôpital Arnaud-de-Villeneuve (F.L.), Montpellier, CHU Angers, Angers (F.R.), CHU Toulouse, Hôpital Rangueil, Toulouse (D.C.), Centre Cardiologique du Nord, Saint-Denis (M.N.), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg (P.O.), Centre Hospitalier Régional Universitaire (CHRU) de Tours, Hôpital Trousseau, Tours (C.S.E.), APHP, Hôpital Henri Mondor, Créteil (E.T.), CHU Bordeaux, Hôpital Haut-Lévêque, Pessac (L.L.), CHRU Brest, Hôpital de La Cavale Blanche, Brest (M.G.), and Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Centre National de la Recherche Scientifique (CNRS), and Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne (F.B., D.M.-B.) - all in France; and the University of Ottawa Heart Institute, Division of Cardiology, Ottawa, Canada (D.M.-Z.).

Background: In patients who have chronic heart failure with reduced left ventricular ejection fraction, severe secondary mitral-valve regurgitation is associated with a poor prognosis. Whether percutaneous mitral-valve repair improves clinical outcomes in this patient population is unknown.

Methods: We randomly assigned patients who had severe secondary mitral regurgitation (defined as an effective regurgitant orifice area of >20 mm or a regurgitant volume of >30 ml per beat), a left ventricular ejection fraction between 15 and 40%, and symptomatic heart failure, in a 1:1 ratio, to undergo percutaneous mitral-valve repair in addition to receiving medical therapy (intervention group; 152 patients) or to receive medical therapy alone (control group; 152 patients). The primary efficacy outcome was a composite of death from any cause or unplanned hospitalization for heart failure at 12 months.

Results: At 12 months, the rate of the primary outcome was 54.6% (83 of 152 patients) in the intervention group and 51.3% (78 of 152 patients) in the control group (odds ratio, 1.16; 95% confidence interval [CI], 0.73 to 1.84; P=0.53). The rate of death from any cause was 24.3% (37 of 152 patients) in the intervention group and 22.4% (34 of 152 patients) in the control group (hazard ratio, 1.11; 95% CI, 0.69 to 1.77). The rate of unplanned hospitalization for heart failure was 48.7% (74 of 152 patients) in the intervention group and 47.4% (72 of 152 patients) in the control group (hazard ratio, 1.13; 95% CI, 0.81 to 1.56).

Conclusions: Among patients with severe secondary mitral regurgitation, the rate of death or unplanned hospitalization for heart failure at 1 year did not differ significantly between patients who underwent percutaneous mitral-valve repair in addition to receiving medical therapy and those who received medical therapy alone. (Funded by the French Ministry of Health and Research National Program and Abbott Vascular; MITRA-FR ClinicalTrials.gov number, NCT01920698 .).
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http://dx.doi.org/10.1056/NEJMoa1805374DOI Listing
December 2018

Multimodality imaging guidance for percutaneous paravalvular leak closure: Insights from the multi-centre FFPP register.

Arch Cardiovasc Dis 2018 Jun - Jul;111(6-7):421-431. Epub 2018 Jun 22.

Faculté de médecine Paris-Sud, hôpital Marie-Lannelongue, université Paris-Sud, Paris-Saclay, 92350 Le Plessis-Robinson, France.

Background: Percutaneous paravalvular leak (PVL) closure has emerged as a palliative alternative to surgical management in selected high-risk patients. Percutaneous procedures are challenging, especially for mitral PVL. Accurate imaging of the morphologies of the defects is mandatory, together with precise guidance in the catheterization laboratory to enhance success rates.

Aims: To describe imaging modalities used in clinical practice to guide percutaneous PVL closure and assess the potential of new imaging tools.

Methods: Data from the 'Fermeture de Fuite paraprothétique' (FFPP) register were used. The FFPP register is an international multi-institutional collaborative register started in 2017 with a retrospective and a prospective part. A descriptive analysis of multimodality imaging used to guide PVL closure in clinical practice was performed.

Results: Data from 173 procedures performed in 19 centres from three countries (France, Belgium and Poland) were collected, which included eight cases of PVL following transcatheter valve replacement. Transoesophageal echocardiography was used in 167 cases (96.5%) and 3D echocardiography in 87.4% of cases. In one case, 3D-echocardiography was fused with fluoroscopy images in real time using echonavigator software. Details about multimodality imaging were available from a sample of 31 patients. Cardiac computed tomography (CT) was performed before 10 of the procedures. In one case, fusion between preprocedural cardiac CT angiography data and fluoroscopy data was used. In two cases, a 3D model of the valve with PVL was printed.

Conclusion: Echocardiography, particularly the 3D mode, is the cornerstone of PVL imaging. Other imaging modalities, such as cardiac CT and cardiac magnetic resonance imaging, may be of complementary interest. New techniques such as imaging fusion and printing may further facilitate the percutaneous approach of PVLs.
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http://dx.doi.org/10.1016/j.acvd.2018.05.001DOI Listing
October 2018

How to treat severe symptomatic structural valve deterioration of aortic surgical bioprosthesis: transcatheter valve-in-valve implantation or redo valve surgery?

Eur J Cardiothorac Surg 2018 12;54(6):977-985

Department of Cardiovascular Diseases and Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.

The optimal management of aortic surgical bioprosthesis presenting with severe symptomatic structural valve deterioration is currently a matter of debate. Over the past 20 years, the number of implanted bioprostheses worldwide has been rapidly increasing at the expense of mechanical prostheses. A large proportion of patients, however, will require intervention for bioprosthesis structural valve deterioration. Current options for older patients who often have severe comorbidities include either transcatheter valve-in-valve (TVIV) implantation or redo valve surgery. The emergence of TVIV implantation, which is perceived to be less invasive than redo valve surgery, offers an effective alternative to surgery for these patients with proven safety and efficacy in high-risk patient groups including elderly and frail patients. A potential caveat to this strategy is that results of long-term follow-up after TVIV implantation are limited. Redo surgery is sometimes preferable, especially for young patients with a smaller-sized aortic bioprosthesis. With the emergence of TVIV implantation and the long experience of redo valve surgery, we currently have 2 complementary treatment modalities, allowing a tailor-made and patient-orientated intervention. In the heart team, the decision-making should be based on several factors including type of bioprosthesis failure, age, comorbidities, operative risk, anatomical factors, anticipated risks and benefits of each alternative, patient's choice and local experience. The aim of this review is to provide a framework for individualized optimal treatment strategies in patients with failed aortic surgical bioprosthesis.
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http://dx.doi.org/10.1093/ejcts/ezy204DOI Listing
December 2018

1-Year Outcomes of Transcatheter Mitral Valve Replacement in Patients With Severe Mitral Annular Calcification.

J Am Coll Cardiol 2018 05;71(17):1841-1853

Division of Cardiology, University of Rouen's Charles Nicolle Hospital, Rouen, France.

Background: The risk of surgical mitral valve replacement in patients with severe mitral annular calcification (MAC) is high. Several patients worldwide with severe MAC have been treated successfully with transcatheter mitral valve replacement (TMVR) using balloon-expandable aortic transcatheter valves. The TMVR in MAC Global Registry is a multicenter registry that collects data on outcomes of these procedures.

Objectives: The goal of this study was to evaluate 1-year outcomes in this registry.

Methods: This study was a multicenter retrospective review of clinical outcomes.

Results: A total of 116 extreme surgical risk patients with severe MAC underwent TMVR; 106 had a procedure date >1 year before data-lock and were included in the analysis. Their mean age was 73 ± 12 years, and 68% were female. The mean Society of Thoracic Surgeons score was 15.3 ± 11.6%, and 90% were in New York Heart Association functional class III or IV. Thirty-day and 1-year all-cause mortality was 25% and 53.7%, respectively. Most patients who survived 30 days were alive at 1 year (49 of 77 [63.6%]), and the majority (71.8%) were in New York Heart Association functional class I or II. Echocardiography data at 1 year were available in 34 patients. Mean left ventricular ejection fraction was 58.6 ± 11.2%, mean mitral valve area was 1.9 ± 0.5 cm, mean mitral gradient was 5.8 ± 2.2 mm Hg, and 75% had zero or trace mitral regurgitation.

Conclusions: TMVR with balloon-expandable aortic valves in extreme surgical risk patients with severe MAC is feasible but associated with high 30-day and 1-year mortality. Most patients who survive the 30-day post-procedural period are alive at 1 year and have sustained improvement of symptoms and transcatheter valve performance. The role of TMVR in patients with MAC requires further evaluation in clinical trials.
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http://dx.doi.org/10.1016/j.jacc.2018.02.054DOI Listing
May 2018

Impact of Pre-Existing Prosthesis-Patient Mismatch on Survival Following Aortic Valve-in-Valve Procedures.

JACC Cardiovasc Interv 2018 01;11(2):133-141

Hospital Universitario Virgen de la Victoria, Malaga, Spain.

Objectives: The aim of this study was to determine whether the association of small label size of the surgical valve with increased mortality after transcatheter valve-in-valve (ViV) implantation is, at least in part, related to pre-existing prosthesis-patient mismatch (PPM) (i.e., a bioprosthesis that is too small in relation to body size).

Background: Transcatheter ViV implantation is an alternative for the treatment of patients with degenerated bioprostheses. Small label size of the surgical valve has been associated with increased mortality after ViV implantation.

Methods: Data from 1,168 patients included in the VIVID (Valve-in-Valve International Data) registry were analyzed. Pre-existing PPM of the surgical valve was determined using a reference value of effective orifice area for each given model and size of implanted prosthetic valve indexed for body surface area. Severe PPM was defined according to the criteria proposed by the Valve Academic Research Consortium 2: indexed effective orifice area <0.65 cm/m if body mass index is <30 kg/m and <0.6 cm/m if BMI is ≥30 kg/m. The primary study endpoint was 1-year mortality.

Results: Among the 1,168 patients included in the registry, 89 (7.6%) had pre-existing severe PPM. Patients with severe PPM had higher 30-day (10.3%, p = 0.01) and 1-year (unadjusted: 28.6%, p < 0.001; adjusted: 19.3%, p = 0.03) mortality rates compared with patients with no severe PPM (4.3%, 11.9%, and 10.9%, respectively). After adjusting for surgical valve label size, Society of Thoracic Surgeons score, renal failure, diabetes, and stentless surgical valves, presence of pre-existing severe PPM was associated with increased risk for 1-year mortality (odds ratio: 1.88; 95% confidence interval: 1.07 to 3.28; p = 0.03). Patients with severe PPM also more frequently harbored high post-procedural gradients (mean gradient ≥20 mm Hg).

Conclusions: Pre-existing PPM of the failed surgical valve is strongly and independently associated with increased risk for mortality following ViV implantation.
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http://dx.doi.org/10.1016/j.jcin.2017.08.039DOI Listing
January 2018

Early Outcomes of Percutaneous Transvenous Transseptal Transcatheter Valve Implantation in Failed Bioprosthetic Mitral Valves, Ring Annuloplasty, and Severe Mitral Annular Calcification.

JACC Cardiovasc Interv 2017 10;10(19):1932-1942

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

Objectives: The aim of this study was to examine 1-year outcomes of transseptal balloon-expandable transcatheter heart valve implantation in failed mitral bioprosthesis, ring annuloplasty, and mitral annular calcification (MAC).

Background: Immediate outcomes following transseptal mitral valve implantation in failed bioprostheses are favorable, but data on subsequent outcomes are lacking.

Methods: Percutaneous transseptal implantation of balloon-expandable transcatheter heart valves was performed in 87 patients with degenerated mitral bioprostheses (valve in valve [VIV]) (n = 60), previous ring annuloplasty (valve in ring) (n = 15), and severe MAC (valve in MAC) (n = 12).

Results: The mean Society of Thoracic Surgeons risk score was 13 ± 8%, and the mean age was 75 ± 11 years. Acute procedural success was achieved in 78 of 87 patients (90%) in the overall group and 58 of 60 (97%) in the VIV group, with a success rate of 20 of 27 (74%) in the valve in ring/valve in MAC group. Thirty-day survival free of death and cardiovascular surgery was 95% (95% confidence interval [CI]: 92% to 97%) in the VIV subgroup and 78% (95% CI: 70% to 86%) in the valve in ring/valve in MAC group (p = 0.008). One-year survival free of death and cardiovascular surgery was 86% (95% CI: 81% to 91%) in the VIV group compared with 68% (95% CI: 58% to 78%) (p = 0.008). At 1 year, 36 of 40 patients (90%) had New York Heart Association functional class I or II symptoms, no patients had more than mild residual mitral prosthetic or periprosthetic regurgitation, and the mean transvalvular gradient was 7 ± 3 mm Hg.

Conclusions: One-year outcomes following successful transseptal balloon-expandable transcatheter heart valve implantation in high-risk patients with degenerated mitral bioprostheses are excellent, characterized by durable symptom relief and prosthesis function. Although mitral valve in ring and valve in MAC have higher operative morbidity and mortality, 1-year outcomes after an initially successful procedure are favorable in carefully selected patients.
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http://dx.doi.org/10.1016/j.jcin.2017.08.014DOI Listing
October 2017

Peristrut microhemorrhages: a possible cause of in-stent neoatherosclerosis?

Cardiovasc Pathol 2017 Jan - Feb;26:30-38. Epub 2016 Aug 29.

INSERM U1148, Université Paris-Diderot, Sorbonne Paris-Cité, DHU-FIRE, Hôpital Bichat, Paris, France. Electronic address:

Background: In-stent neoatherosclerosis is characterized by the delayed appearance of markers of atheroma in the subintima, but the pathophysiology underlying this new disease entity remains unclear.

Methods And Results: We collected 20 human coronary artery stents by removal from explanted hearts. The mean duration of stent implantation was 34 months. In all samples, neoatherosclerosis was detected, particularly in peristrut areas. It consisted of foam cells and cholesterol clefts, with or without calcification, associated with neovascularization. Iron and glycophorin-A were present in peristrut areas, as well as autofluorescent ceroids. Moreover, in response to neoatherosclerosis, tertiary lymphoid organs (tissue lymphoid clusters) often developed in the adventitia. Some of these features could be reproduced in an experimental carotid stenting model in rabbits fed a high-cholesterol diet. Foam cells were present in all samples, and peristrut red blood cells (RBCs) were also detected, as shown by iron deposits and Bandeiraea simplicifiola isolectin-B4 staining of RBC membranes. Finally, in silico models were used to evaluate the compliance mismatch between the rigid struts and the distensible arterial wall using finite element analysis. They show that stenting approximately doubles the local von Mises stress in the intimal layer.

Conclusions: We show here that stent implantation both in human and in rabbit arteries is characterized by local peristrut microhemorrhages and finally by both cholesterol accumulation and oxidation, triggering together in-stent neoatherosclerosis. Our data indicate that these processes are likely initiated by an increased mechanical stress due to the compliance mismatch between the rigid stent and the soft wall.
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http://dx.doi.org/10.1016/j.carpath.2016.08.007DOI Listing
January 2017

First-in-man full percutaneous transfemoral valve-in-valve implantations using Edwards SAPIEN 3 prostheses to treat a patient with degenerated mitral and aortic bioprostheses.

Interact Cardiovasc Thorac Surg 2016 09 30;23(3):508-10. Epub 2016 May 30.

Department of Cardiology, Centre Cardiologique du Nord, Saint Denis, France

We report the case of a 64-year old man presenting with pulmonary oedema due to the degeneration of mitral and aortic bioprostheses. Baseline transthoracic and 3D transoesophageal echocardiography showed severe stenotic degeneration of the mitral bioprosthesis (Carpentier-Edwards bioprosthesis n°31), severe intraprosthetic aortic regurgitation (Perimount bioprosthesis n°27), left ventricular dilatation, decreased left ventricular ejection fraction at 50% and pulmonary hypertension. Because of severe comorbidities, the patient was denied redo surgery by the Heart Team (logistic EuroSCORE 2: 23, 85%). Transcatheter transfemoral mitral valve-in-valve implantation was first performed using a 29-mm SAPIEN 3 valve. Two weeks later, aortic valve-in-valve implantation was performed with the same approach using a 26-mm SAPIEN 3 valve. Four months later, the patient remained asymptomatic with good haemodynamic results for both prostheses. This case report illustrates that valve-in-valve implantations using a full percutaneous transfemoral approach may be a valuable alternative to conventional surgery in high-risk patients presenting with concomitant mitral and aortic bioprosthesis dysfunction.
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http://dx.doi.org/10.1093/icvts/ivw161DOI Listing
September 2016

Spectral contrast-enhanced cardiac computed tomography for diagnosis of acute myocarditis.

Can J Cardiol 2015 May 24;31(5):691.e9-691.e10. Epub 2014 Dec 24.

Department of Radiology, University Paris Diderot, Hôpital Bichat, APHP, Paris, France.

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http://dx.doi.org/10.1016/j.cjca.2014.12.022DOI Listing
May 2015

Transfemoral tricuspid valve-in-ring implantation using the edwards Sapien XT valve: one-year follow-up.

Circ Cardiovasc Interv 2015 Mar;8(3)

From the Departments of Cardiology (C.B., D.H., E.B., B.I., M.N., A.-A.F., A.V.), Cardiovascular Surgery (W.G.), Anesthesiology (J.-P.D.), and Radiology (P.O.), Bichat-Claude-Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Paris, France.

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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.114.002225DOI Listing
March 2015

Impact of participation in randomized trials of reperfusion therapy on the time to reperfusion and hospital mortality in ST-segment elevation myocardial infarction: A single-centre cohort study.

Eur Heart J Acute Cardiovasc Care 2016 Apr 27;5(2):193-7. Epub 2015 Feb 27.

Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Université Paris-Diderot, Sorbonne Paris-Cité, INSERM U-1148, Paris, France NHLI Imperial College, ICMS Royal Brompton Hospital, London, UK.

Aim: There is uncertainty as to whether consenting and randomizing patients in randomized clinical trials (RCTs) in acute ST-segment elevation myocardial infarction (STEMI) delays reperfusion and increases mortality. The aim of this study was to determine whether participation of patients with STEMI in RCTs is associated with delay in implementation of reperfusion therapy and increased hospital mortality.

Methods And Results: A consecutive sample of 2523 patients, admitted within 6 hours of symptom onset without cardiogenic shock, was recruited from a single tertiary academic centre. They were categorized according to participation (n=392, 15.5%) or nonparticipation (n=2131, 84.5%) in RCTs of reperfusion therapy. Primary outcome was hospital mortality. Additional outcome was time from symptom onset to receipt of reperfusion therapy. Trial participants were more likely to receive fibrinolysis with a 37 min delay in comparison with patients not included in RCTs. Time from symptom onset to reperfusion (minutes) was longer for trial participants than nonparticipants (246 ± 85 vs 233 ± 93, p=0.01). Hospital mortality was 3.61% for nonparticipants. Expected mortality (based on risk modeling) for trial participants was 2.74% (p=0.014 vs nonparticipants). Observed mortality was 1.53% (p=0.034 vs nonparticipants; p=0.16 vs expected mortality). In a multivariable analysis using logistic regression, participation in a RCT was not an independent correlate of hospital mortality (odds ratio 0.54, 95% confidence interval 0.23-2.43, p=0.16).

Conclusions: In this consecutive cohort, despite a longer delay to reperfusion, there was no indication that participation in a RCT, starting before initiation of reperfusion therapy, was associated with a detectable increase in risk of hospital mortality among patients with STEMI. These data suggest that it is possible to consent and randomize patients with STEMI into RCTs without jeopardizing their survival.
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http://dx.doi.org/10.1177/2048872615574108DOI Listing
April 2016

Transfemoral implantation of transcatheter heart valves after deterioration of mitral bioprosthesis or previous ring annuloplasty.

JACC Cardiovasc Interv 2015 Jan;8(1 Pt A):83-91

Department of Cardiology, Bichat-Claude-Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Paris, France.

Objectives: This study sought to evaluate the feasibility of transfemoral transcatheter heart valve (THV) implantation in failed mitral bioprostheses and ring annuloplasties.

Background: Redo mitral surgery may be high risk or contraindicated due to comorbidity. THV implantation has been recently reported in this setting.

Methods: Transfemoral implantation of Edwards Sapien prosthesis was performed in 17 patients for degenerated mitral bioprosthesis or previous ring annuloplasty (6 bioprostheses, 11 ring annuloplasties). The procedure was elective for 14 patients and attempted as a rescue in 3 patients. Mean age was 61 ± 24 years. All patients were in New York Heart Association class ≥III, and the surgical risk was high (EuroSCORE [European System for Cardiac Operative Risk Evaluation]: 37 ± 29%, Society of Thoracic Surgeons score: 18 ± 22%).

Results: Procedure was successful in 14 patients (82%). Two complications occurred during rescue procedures: 1 procedural death and 1 THV migration. One patient had moderate paraprosthetic regurgitation following the procedure, whereas residual regurgitation was trace or less in 11 patients (69%) and mild in 4 patients (25%). Mean gradient decreased from 12 ± 6 mm Hg to 8 ± 3 mm Hg. During a mean follow-up of 22 months, 4 patients died, 3 from cardiac cause. The 18-month survival was 68 ± 14% in the overall population and 78 ± 14% for patients with elective procedure. One patient underwent mitral valve replacement due to periprosthetic mitral regurgitation. At last follow-up, 12 patients were in New York Heart Association class ≤II (75%) and 4 in class III (25%).

Conclusions: This single-center series suggests that transfemoral THV implantation for deterioration of mitral bioprosthesis or surgical repair is feasible in selected patients and improves early hemodynamic and midterm functional status.
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http://dx.doi.org/10.1016/j.jcin.2014.07.026DOI Listing
January 2015

Update on the need for a permanent pacemaker after transcatheter aortic valve implantation using the CoreValve® Accutrak™ system.

EuroIntervention 2012 Sep;8(5):556-62

Groupe CardioVasculaire Interventionnel, Clinique Pasteur, Toulouse, France.

Aims: High rates of permanent pacemaker (PPM) implantation are reported after transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve® system. The Accutrak™ catheter is designed to allow a more predictable landing zone. Little is known about the real clinical impact of this catheter. The aims of this paper were to describe the potential impact of the Accutrak™ catheter on the accuracy of positioning a 26 or 29 mm CoreValve® across the aortic annulus and its impact on the need for a pacemaker.

Methods And Results: A total of 134 patients were treated with the CoreValve® Accutrak™ system at two French centres (Lille and Toulouse). Mean age was 82.4 ± 4.7 years; logistic EuroSCORE was 24.3 ± 9.5%. Procedural success rate was 99.2%; mean depth of implantation was 4.9 mm. A final position between 0 and 6 mm was achieved in 85.8% of the patients. All-cause mortality at 30 days was 6%. The PPM implantation rate was 10.6%. Due to a limited number of events, we could not identify any predictor of need for a PPM: pre-existing right bundle branch block (RBBB) (OR 2.72 [0.63-11.87], p=ns), use of a 29 mm prosthesis (OR 2.73 [0.33-22.90], p=ns) and left ventricular septal hypertrophy (OR 2.63 [0.08-83.32], p=ns).

Conclusions: In this cohort of patients treated with the CoreValve® Accutrak™ system, the incidence of permanent pacemaker implantation was low, which may be a consequence of an average small implantation depth. The Accutrak™ catheter seems to be helpful in achieving higher and more predictable implants. Operators could standardise their technique to place the CoreValve® prostheses less than 6 mm below the aortic annulus.
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http://dx.doi.org/10.4244/EIJV8I5A86DOI Listing
September 2012