Arrhythmias in Patients With Valvular Heart Disease: Gaps in Knowledge and the Way Forward.

peer reviewedThe prevalence of both organic valvular heart disease (VHD) and cardiac arrhythmias is high in the general population, and their coexistence is common. Both VHD and arrhythmias in the elderly lead to an elevated risk of hospitalization and use of health services. However, the relationships of the two conditions is not fully understood and our understanding of their coexistence in terms of contemporary management and prognosis is still limited. VHD-induced left ventricular dysfunction/hypertrophy and left atrial dilation lead to both atrial and ventricular arrhythmias. On the other hand, arrhythmias can be considered as an independent condition resulting from a coexisting ischemic or non-ischemic substrate or idiopathic ectopy. Both atrial and ventricular VHD-induced arrhythmias may contribute to clinical worsening and be a turning point in the natural history of VHD. Symptoms developed in patients with VHD are not specific and may be attributable to hemodynamical consequences of valve disease but also to other cardiac conditions including arrhythmias which are notably prevalent in this population. The issue how to distinguish symptoms related to VHD from those related to atrial fibrillation (AF) during decision making process remains challenging. Moreover, AF is a traditional limit of echocardiography and an important source of errors in assessment of the severity of VHD. Despite recent progress in understanding the pathophysiology and prognosis of postoperative AF, many questions remain regarding its prevention and management. Furthermore, life-threatening ventricular arrhythmias can predispose patients with VHD to sudden cardiac death. Evidence for a putative link between arrhythmias and outcome in VHD is growing but available data on targeted therapies for VHD-related arrhythmias, including monitoring and catheter ablation, is scarce. Despite growing evidences, more research focused on the prognosis and optimal management of VHD-related arrhythmias is still required. We aimed to review the current evidence and identify gaps in knowledge about the prevalence, prognostic considerations, and treatment of atrial and ventricular arrhythmias in common subtypes of organic VHD

Comparison of effective regurgitant orifice area by the PISA method and tricuspid coaptation gap measurement to identify very severe tricuspid regurgitation and stratify mortality risk

IntroductionVarious definitions of very severe (VS) tricuspid regurgitation (TR) have been proposed based on the effective regurgitant orifice area (EROA) or tricuspid coaptation gap (TCG). Because of the inherent limitations associated with the EROA, we hypothesized that the TCG would be more suitable for defining VSTR and predicting outcomes.Materials and methodsIn this French multicentre retrospective study, we included 606 patients with ≥moderate-to-severe isolated functional TR (without structural valve disease or an overt cardiac cause) according to the recommendations of the European Association of Cardiovascular Imaging. Patients were further stratified into VSTR according to the EROA (≥60 mm2) and then according to the TCG (≥10 mm). The primary endpoint was all-cause mortality and the secondary endpoint was cardiovascular mortality.ResultsThe relationship between the EROA and TCG was poor (R2 = 0.22), especially when the size of the defect was large. Four-year survival was comparable between patients with an EROA <60 mm2 vs. ≥60 mm2 (68 ± 3% vs. 64 ± 5%, p = 0.89). A TCG ≥10 mm was associated with lower four-year survival than a TCG <10 mm (53 ± 7% vs. 69 ± 3%, p < 0.001). After adjustment for covariates, including comorbidity, symptoms, dose of diuretics, and right ventricular dilatation and dysfunction, a TCG ≥10 mm remained independently associated with higher all-cause mortality (adjusted HR[95% CI] = 1.47[1.13–2.21], p = 0.019) and cardiovascular mortality (adjusted HR[95% CI] = 2.12[1.33–3.25], p = 0.001), whereas an EROA ≥60 mm2 was not associated with all-cause or cardiovascular mortality (adjusted HR[95% CI]: 1.16[0.81–1.64], p = 0.416, and adjusted HR[95% CI]: 1.07[0.68–1.68], p = 0.784, respectively)ConclusionThe correlation between the TCG and EROA is weak and decreases with increasing defect size. A TCG ≥10 mm is associated with increased all-cause and cardiovascular mortality and should be used to define VSTR in isolated significant functional TR

Characteristics, management, and outcomes of patients with multiple native valvular heart disease: a substudy of the EURObservational Research Programme Valvular Heart Disease II Survey

Aims To assess the characteristics, management, and survival of patients with multiple native valvular heart disease (VHD). Methods and results Among the 5087 patients with >= 1 severe left-sided native VHD included in the EURObservational VHD II Survey (maximum 3-month recruitment period per centre between January and August 2017 with a 6-month follow-up), 3571 had a single left-sided VHD (Group A, 70.2%), 363 had one severe left-sided VHD with moderate VHD of the other ipsilateral valve (Group B, 7.1%), and 1153 patients (22.7%) had >= 2 severe native VHDs (left-sided and/or tricuspid regurgitation, Group C). Patients with multiple VHD (Groups B and C) were more often women, had greater congestive heart failure (CHF) and comorbidity, higher left atrial volumes and pulmonary pressures, and lower ejection fraction than Group A patients (all P <= 0.01). During the index hospitalization, 36.7% of Group A (n = 1312), 26.7% of Group B (n = 97), and 32.7% of Group C (n = 377) underwent valvular intervention (P < 0.001). Six-month survival was better for Group A than for Group B or C (both P < 0.001), even after adjustment for age, sex, body mass index, and Charlson index [hazard ratio (HR) 95% confidence interval (CI) 1.62 (1.10-2.38) vs. Group B and HR 95% CI 1.72 (1.32-2.25) vs. Group C]. Groups B and C had more CHF at 6 months than Group A (both P < 0.001). Factors associated with mortality in Group C were age, CHF, and comorbidity (all P < 0.010). Conclusion Multiple VHD is common, encountered in nearly 30% of patients with left-sided native VHD, and associated with greater cardiac damage and leads to higher mortality and more heart failure at 6 months than single VHD, yet with lower rates of surgery

Sténose aortique à fraction d'éjection ventriculaire gauche préservée : identification de facteurs pronostiques et étude des formes discordantes avec surface basse, débit normal et bas gradient et à haut gradient haute surface.

The only curative treatment of severe Aortic stenosis (AS) is aortic valve replacement (AVR) which is currently recommended in case of symptoms or in asymptomatic individuals with a high risk of adverse events. However, severe AS mainly affects elderly patients for whom symptom assessment can be very challenging and it is crucial to identify prognostic factors in this population in order to select patients who will benefit from early AVR. Another challenge in AS is the echocardiographic assessment of its severity. Indeed, in approximately 30% of patients, discrepancies between mean gradient (MG) and aortic valve area (AVA) are observed in clinical practice and normal flow-low gradient "severe" AS is a frequent finding with debated severity and outcomes. Conversely, discordant high gradient AS (MG>/=40 mmHg and AVA>/=1cm²) is a relatively rare situation with very few data available. The objectives of this thesis were threefold: (i) to identify new prognosis factors in severe AS, (ii) to assess the outcome and progression of normal flow-low gradient "severe" AS and (iii) to compare patients with concordant (AVA/=50%), that LVEF remains of paramount importance for risk stratification. Patients with LVEF between 50 and 55% experience poor outcomes compare to those with LVEF greater than 60%. This excess mortality is observed with medical or surgical management but AVR remains beneficial in those with LVEF/=1cm²) and despite the lack of data, European guidelines recommend to consider these patients as severe AS after excluding a reversible high flow condition. We show, after propensity matching, that in routine clinical practice, these patients are referred less often for AVR and later than patients with concordant high gradient AS, resulting in excess mortality. Consequently, in cases of high gradient, physicians should not be reassured by the fact that the AVA is >/=1cm².Le seul traitement curatif du rétrécissement aortique (RA) est le remplacement valvulaire aortique (RVA), actuellement recommandé en cas de symptômes ou chez les patients asymptomatiques à haut risque. Néanmoins, cette pathologie touche essentiellement des patients âgés, chez qui l'évaluation des symptômes peut s'avérer difficile et il est donc crucial de rechercher des facteurs pronostiques afin d'identifier les patients qui bénéficieront d'un RVA précoce. Un autre défi est l'évaluation échocardiographique de la sévérité du RA. Dans environ 30 % des cas, des divergences entre le gradient moyen (GM) et la surface valvulaire aortique (SVA) sont observées comme le RA à débit normal-bas gradient (DN-BG) qui est fréquent et dont la sévérité et le pronostic sont discutés. À l'inverse, le RA discordant à haut gradient (GM>/=40 mmHg et SVA>/=1cm²) est relativement rare et peu étudié. Les objectifs de cette thèse étaient triples : (i) identifier de nouveaux facteurs pronostique dans le RA serré, (ii) étudier le pronostic et la progression du RA serré DN-BG et (iii) comparer les RA serrés à haut gradient concordants (SVA/=50%). Les patients avec FEVG entre 50 et 55% présentent une surmortalité par rapport au groupe FEVG>60%. Cet excès de mortalité est observé sous surveillance médicale ou après RVA mais le RVA reste bénéfique en cas de FEVG/=1cm²) et, malgré le manque de données, il est recommandé de considérer ces patients comme des RA serré après avoir exclu une cause réversible d'hyperdébit. Nous montrons, après appariement, qu'en pratique clinique, ces patients sont moins souvent référés pour un RVA et plus tardivement que les patients avec un RA concordant à haut gradient, ce qui entraîne une surmortalité. Par conséquent, en cas de gradient élevé, les cardiologues ne doivent pas être rassurés par le fait que la SVA soit >/= 1cm

Aortic stenosis with preserved left ventricular ejection fraction : identification of prognostic factors and study of discordant forms with normal flow-low gradient and high gradient-high aortic valve area.

Le seul traitement curatif du rétrécissement aortique (RA) est le remplacement valvulaire aortique (RVA), actuellement recommandé en cas de symptômes ou chez les patients asymptomatiques à haut risque. Néanmoins, cette pathologie touche essentiellement des patients âgés, chez qui l'évaluation des symptômes peut s'avérer difficile et il est donc crucial de rechercher des facteurs pronostiques afin d'identifier les patients qui bénéficieront d'un RVA précoce. Un autre défi est l'évaluation échocardiographique de la sévérité du RA. Dans environ 30 % des cas, des divergences entre le gradient moyen (GM) et la surface valvulaire aortique (SVA) sont observées comme le RA à débit normal-bas gradient (DN-BG) qui est fréquent et dont la sévérité et le pronostic sont discutés. À l'inverse, le RA discordant à haut gradient (GM>/=40 mmHg et SVA>/=1cm²) est relativement rare et peu étudié. Les objectifs de cette thèse étaient triples : (i) identifier de nouveaux facteurs pronostique dans le RA serré, (ii) étudier le pronostic et la progression du RA serré DN-BG et (iii) comparer les RA serrés à haut gradient concordants (SVA/=50%). Les patients avec FEVG entre 50 et 55% présentent une surmortalité par rapport au groupe FEVG>60%. Cet excès de mortalité est observé sous surveillance médicale ou après RVA mais le RVA reste bénéfique en cas de FEVG/=1cm²) et, malgré le manque de données, il est recommandé de considérer ces patients comme des RA serré après avoir exclu une cause réversible d'hyperdébit. Nous montrons, après appariement, qu'en pratique clinique, ces patients sont moins souvent référés pour un RVA et plus tardivement que les patients avec un RA concordant à haut gradient, ce qui entraîne une surmortalité. Par conséquent, en cas de gradient élevé, les cardiologues ne doivent pas être rassurés par le fait que la SVA soit >/= 1cm²The only curative treatment of severe Aortic stenosis (AS) is aortic valve replacement (AVR) which is currently recommended in case of symptoms or in asymptomatic individuals with a high risk of adverse events. However, severe AS mainly affects elderly patients for whom symptom assessment can be very challenging and it is crucial to identify prognostic factors in this population in order to select patients who will benefit from early AVR. Another challenge in AS is the echocardiographic assessment of its severity. Indeed, in approximately 30% of patients, discrepancies between mean gradient (MG) and aortic valve area (AVA) are observed in clinical practice and normal flow-low gradient "severe" AS is a frequent finding with debated severity and outcomes. Conversely, discordant high gradient AS (MG>/=40 mmHg and AVA>/=1cm²) is a relatively rare situation with very few data available. The objectives of this thesis were threefold: (i) to identify new prognosis factors in severe AS, (ii) to assess the outcome and progression of normal flow-low gradient "severe" AS and (iii) to compare patients with concordant (AVA/=50%), that LVEF remains of paramount importance for risk stratification. Patients with LVEF between 50 and 55% experience poor outcomes compare to those with LVEF greater than 60%. This excess mortality is observed with medical or surgical management but AVR remains beneficial in those with LVEF/=1cm²) and despite the lack of data, European guidelines recommend to consider these patients as severe AS after excluding a reversible high flow condition. We show, after propensity matching, that in routine clinical practice, these patients are referred less often for AVR and later than patients with concordant high gradient AS, resulting in excess mortality. Consequently, in cases of high gradient, physicians should not be reassured by the fact that the AVA is >/=1cm²

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

SCOPUS: ed.jinfo:eu-repo/semantics/publishe

Risk Stratification of Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction Using Peak Aortic Jet Velocity An Outcome Study

International audienceBackground-Current guidelines consider aortic valve replacement reasonable in asymptomatic patients with very severe aortic stenosis (AS); however, the definition of very severe AS based on peak aortic jet velocity (Vmax) remains unclear with a 5-m/s cutoff in US guidelines and 5.5 m/s in European guidelines. Because approximate to 20% of patients with severe AS and preserved left ventricular ejection fraction have Vmax in this range, we aimed to assess the relationship between Vmax and mortality and determine the best threshold to define very severe AS. Methods and Results-A total of 1140 patients with severe AS (aortic valve area = 4 m/s) and preserved left ventricular ejection fraction were included. The population was divided into 4 groups according to Vmax (4-4.49, 4.5-4.99, 5-5.49, and >= 5.5 m/s). After adjustment for covariates (including surgery), there was no difference in all-cause mortality between Vmax 4 to 4.49 m/s and Vmax 4.5 to 4.99 m/s (P=0.64). Both Vmax 5 to 5.49 m/s and Vmax >= 5.5 m/s exhibited significant excess mortality compared with Vmax 4 to 4.49 m/s (adjusted hazard ratio=1.34 [1.18-1.52]; P= 5.5 m/s (P=0.93). Compared with Vmax = 5 m/s had greater mortality risk (adjusted hazard ratio=1.86 [1.55-2.54]; P= 5 m/s at the time of AS diagnosis identifies patients with very severe AS at high risk of death

Modeling of mitral chordae’s length in echocardiography as a function of their manual measurement in the operating room

International audienceAbstract Objective In mitral insufficiency, trans-esophageal echocardiography (TEE) analysis of the mitral valve is an indispensable and irreplaceable examination to establish precisely the type of surgical repair to be performed and the exact length of neo-chordae to be used for an anatomical repair. The aim of our study is to find a predictive model of the Echographic Measurement (EM) variable according to the Manual Measurement (MM) variable of the mitral valve chordae, when the echocardiography measurement is not feasible. Patients and methods This is a retrospective study on 191 patients undergoing mitral valve repair. The sex ratio (M/F) is 2.13 (130 men and 61 women). The collection of data of mitral chordae measurements performed echographically in preoperatively conditions, and then manually in intraoperatively conditions from January 2008 to December 2016 was made from the medical records of patients at the cardiology and cardiac surgery department of the University Hospital Center of Amiens in Picardy. Results For this study 191 patients of mean age of 68 ± 13 years were included. The averages of the MM and EM of the mitral chordae were respectively 23 ± 2.5 mm and 24 ± 2.4 mm. The Pearson correlation coefficient was 0.897 ( p -value < 10 −4 ) showing a strong positive correlation between MM and EM. The results of the linear regression allow us to found the following mathematical model: EM = 0.87 × MM + 4. Conclusions When patients have a contraindication to transesophageal echocardiography or when TEE is not feasible, manual measurement is performed during the surgery. By using the values obtained (MM) in the model, it is possible to predict the corresponding echographic measurements. This allows us to achieve the mitral tendinous chordae substitution with a very high precision. Trial registration : Retrospectively registered

Impact of Preoperative Left Atrial Dimension on Outcome in Patients in Sinus Rhythm Undergoing Surgical Valve Repair for Severe Mitral Regurgitation due to Mitral Valve Prolapse

International audienceBackground: Left atrial (LA) enlargement has been previously identified as a predictor of mortality in patients with medically managed mitral regurgitation (MR) due to mitral valve prolapse (MVP). No study has specifically assessed the prognostic value of LA size in patients undergoing mitral valve repair (MVRp). Objective: We aimed to investigate the relationship between LA area and mortality in patients in sinus rhythm (SR) undergoing MVRp for MVP. Methods: We included 305 patients in SR who underwent MVRp for MVP. Median follow-up time was 7.9 years. Patients were divided into 3 groups: LA area 30 cm(2). Results: Compared with patients with an LA area 30 cm(2) had a lower 10-year survival (98 +/- 2 vs. 86 +/- 4%; p = 0.037). In multivariate analysis, after adjustment for established outcome predictors including age, symptoms, EuroSCORE, and left ventricular size and function, LA enlargement >30 cm(2) was associated with increased mortality (adjusted HR = 2.20, 95% CI 1.03-4.90; p = 0.042), whereas LA enlargement between 26 and 30 cm(2) was not (adjusted HR = 1.37, 95% CI 0.56-3.56; p = 0.52). Conclusion: LA enlargement is independently predictive of long-term mortality after MVRp in patients in SR with severe MR due to MVP. Our findings suggest that MVRp should be considered before the LA area exceeds 30 cm(2)

Tricuspid Longitudinal Annular Displacement for the Assessment of Right Ventricular Systolic Dysfunction during Prone Positioning in Patients with COVID-19

International audienc