Physiopathologie et prise en charge des insuffisances valvulaires aortiques et mitrales combinées

peer reviewedThe combination of aortic and mitral regurgitation is a typical example of a frequent yet understudied multiple valve disease scenario. The aetiology is often rheumatic or degenerative; less frequently it can be induced by drugs or radiation, or caused by infective endocarditis or congenital valvular lesions. Aortic regurgitation resulting in secondary mitral regurgitation is also not uncommon. There are limited data to guide the management of combined aortic and mitral regurgitation. Left ventricular dysfunction is frequent at initial presentation, and even more so postoperatively, suggesting that surgical management should not be delayed, particularly when symptoms occur or when there is evidence of even subtle left ventricular dysfunction. The decision to operate on one or both valves not only depends on the severity of each lesion, but also on several other factors, including age, co-morbidities and frailty, the increased operative risk of double valve surgery, the increased risk of long-term thrombotic and bleeding complications with multiple mechanical valves, the risk of leaving one valve unoperated and the probability of requiring redo surgery. The role of a multidisciplinary heart valve team is critical in this setting to optimize management and outcomes. The role of transcatheter approaches is currently limited, but technological advances will probably soon change the management paradigm. © 2019 Elsevier Masson SA

Pulmonary transit time is a better predictor of cardiovascular mortality and HF hospitalization in HF-rEF patients than left and right ventricular ejection fraction or feature tracking GLS

Background: Right ventricular (RV) ejection fraction and hemodynamic congestion are known as powerful predictor of mortality in HF-rEF. Pulmonary transit time (PTT) assessed by cMR is a novel parameter, which reflects multiple indicators of cardiopulmonary status, including not only left ventricular(LV) and RV function but also hemodynamic congestion. Purpose: We sought to explore the prognostic value of the PTT above well-known risk factor for predicting outcomes in HF-rEF in direct comparison with cardiac function assessed either by the conventional cMR-systolic parameters or by cMR-feature tracking (FT). Methods: 401 patients in sinus rhythm with a LVEF 40mmHg, E/A ratio, e/e’ratio, cMR-RVEF, LVEF, LV scar, PTT, GFR, beta blockers and diuretics were associated with the composite endpoint. For the multivariate analysis, a baseline model was created where age, female sex, ischemic etiology, diabetes, eSPAP > 40mmHg, diuretics, beta blockers were found to be significantly associated with the endpoint. PTT (X2 to improve = 9.41, HR: 1.04; 95%CI: [1.02; 1.06]; P = 0.002) showed a significantly higher additional prognostic value over the baseline model than cMR-LVEF (X2 to improve = 1.15, HR: 0.99; 95%CI: [0.97; 1.01]; P = 0.28), cMR-RVEF (X2 to improve = 7.36, HR: 0.99; 95%CI: [0.97; 0.99]; P = 0.007), LV-FT-cMR(X2 to improve = 1.36, HR: 1.03; 95%CI: [0.98; 1.08]; P = 0.24) and RV-FT-cMR (X2 to improve = 2.32, HR: 1.03; 95%CI: [0.99; 1.06]; P = 0.28). Conclusion: Pulmonary transit time provides higher prognostic information than cardiac function assessed by cMR or by cMR feature tracking over well-known risk factors with high power to stratify prognosis in HF-rEF and might be promising tools to identify patients at higher risk among HF patients

Meta-Analysis of the Prognostic Role of Late Gadolinium Enhancement and Global Systolic Impairment in Left Ventricular Noncompaction.

The objective of this meta-analysis was to assess the predictive value of late gadolinium enhancement (LGE) and global systolic impairment for future major adverse cardiovascular events in left ventricular noncompaction (LVNC). The prognosis of patients with LVNC, with and without left ventricular dysfunction and LGE, is still unclear. A systematic review of published research and a meta-analysis reporting a combined endpoint of hard (cardiac death, sudden cardiac death, appropriate defibrillator firing, resuscitated cardiac arrest, cardiac transplantation, assist device implantation) and minor (heart failure hospitalization and thromboembolic events) events was performed. Four studies with 574 patients with LVNC and 677 with no LVNC and an average follow-up duration of 5.2 years were analyzed. In patients with LVNC, LGE was associated with the combined endpoint (pooled odds ratio: 4.9; 95% confidence interval: 1.63 to 14.6; p = 0.005) and cardiac death (pooled odds ratio: 9.8; 95% confidence interval: 2.44 to 39.5; p < 0.001). Preserved left ventricular systolic function was found in 183 patients with LVNC: 25 with positive LGE and 158 with negative LGE. In LVNC with preserved ejection fraction, positive LGE was associated with hard cardiac events (odds ratio: 6.1; 95% confidence interval: 2.1 to 17.5; p < 0.001). No hard cardiac events were recorded in patients with LVNC, preserved ejection fraction, and negative LGE. Patients with LVNC but without LGE have a better prognosis than those with LGE. When LGE is negative and global systolic function is preserved, no hard cardiac events are to be expected. Currently available criteria allow diagnosis of LVNC, but to further define the presence and prognostic significance of the disease, LGE and/or global systolic impairment must be considered for better risk stratification

231Global myocardial longitudinal strain by feature tracking cardiac magnetic resonance does not influence the prognosis of patients with heart failure with reduced ejection fraction

Background Feature tracking (FT) cardiac magnetic resonance (cMR) is a new technique to evaluate myocardial deformation and was sug-gested it could refine prognosis of patients with various cardiac diseases. Objectives. To evaluate the impact of global myocardial longitudinal strain (GLS) FT cMR on outcomes of patients with non-ischemic dilatedcardiomyopathy (DCM) and ischemic heart disease (ISCH) presenting heart failure with reduced ejection fraction (HFrEF). Methods FT GLS was computed in 401 consecutive patients (167 pts DCM and 234 pts ISCH) with LVEF < 40% undergoing cMR. Theprognostic value of GLS for the primary endpoint of overall death and secondary endpoint of cardiovascular (CV) death was assessed. Conclusions. GLS by FT cMR in ISCH and DCM patients with HFrEF did not add significant prognostic value over baseline clinical and cMRparameters

Three-dimensional echocardiographic quantification of the left-heart chambers using an automated adaptive analytics algorithm: multicentre validation study.

AIMS: Although recommended by current guidelines, adoption of three-dimensional echocardiographic (3DE) chamber quantification in clinical practice has lagged because of time-consuming analysis. We recently validated an automated algorithm that measures left atrial (LA) and left ventricular (LV) volumes and ejection fraction (EF). This study aimed to determine the accuracy and reproducibility of these measurements in a multicentre setting. METHODS AND RESULTS: 180 patients underwent 3DE imaging (Philips) at six sites. Images were analysed using automated HeartModel (HM) software with endocardial border correction when necessary and by manual tracing. Measurements were performed by each site and by the Core Laboratory (CL) as the reference. Inter-technique comparisons included HM measurements by the sites against manual tracing by CL, and showed strong correlations (r-values: LVEDV: 0.97, LVESV: 0.97, LVEF: 0.88, LAV: 0.96), with the automated technique slightly underestimating LV volumes (biases: LVEDV: -14 ± 20 ml, LVESV: -6 ± 20 ml), LVEF (-2 ± 7%) and LAV (-9 ± 10 ml). Intra-technique comparisons included HM measurements by the sites against CL, with and without corrections. Corrections were unnecessary or minimal in most patients, and improved the measurements only modestly. Comparisons without corrections showed perfect agreement for all parameters. With corrections, correlations were better (r-values: LVEDV: 0.99, LVESV: 0.99, LVEF: 0.94, LAV: 0.99) and biases (LVEDV: -8 ± 12 ml, LVESV: -6 ± 12 ml, LVEF: 1 ± 5%, LAV: -10 ± 6 ml) smaller than in inter-technique comparison. All automated measurements with corrections were more reproducible than manual measurements. CONCLUSION: Automated 3DE analysis of left-heart chambers is an accurate alternative to conventional manual methodology, which yields almost the same values across laboratories and is more reproducible. This technique may contribute towards full integration of 3DE quantification into clinical routine