0274: Prognostic impact of pulmonary arterial pressure in patients with aortic stenosis and preserved left ventricular ejection fraction

BackgroundThe prognostic impact of pulmonary arterial pressure (PAP) remains controversial in aortic stenosis (AS) and few studies focused only on patients with preserved left ventricular ejection fraction (LVEF). We therefore aimed to investigate the impact of PAP, derived from our large catheterization database, on survival in severe AS with preserved LVEF.Methods and resultsBetween 2000 and 2010, 749 patients (74±8y, 57% of males) with preserved LVEF and severe AS without other valvular heart disease underwent cardiac catheterization, including right heart hemodynamic assessment. Pulmonary hypertension (PH) was defined as mean PAP>25mmHg.Systolic and mean PAP were 34.5±12 and 21.9±9mmHg, respectively. Overall, 29% (n=215) of patients had PH, and these patients were significantly older (p<0.0001), with lower LVEF (p<0.0001) and higher heart rate (p=0.016) than those without PH. In addition, they more frequently had, hypertension (p<0.0001), diabetes (p=0.001), coronary artery disease (CAD, p<0.0001) and chronic pulmonary disease (p=0.043). Aortic valve replacement (AVR) was performed in 91% of patients and 30-day mortality was 4.3%, significantly higher in patients with PH (7.7 vs. 3.4%, p=0.014). In logistic regression analysis, after adjustment for age, gender, LVEF, CAD and mean transaortic pressure gradient, mean PAP was an independent predictor of increased 30-day mortality (OR=1.06, 95% CI: 1.02-1.1, p=0.004). Overall long-term survival was significantly reduced in patients with PH as compared to those without PH (10-year survival: 41±8 vs. 61±3%, p<0.0001). In multivariate analysis, after adjustment for all cofactors, PH was an independent predictor of mortality (HR=1.5, 95% CI: 1.1-2.1, p=0.037).ConclusionIn patients with severe AS and preserved LVEF, PAP is an independent predictor of both 30-day and long-term mortality. In order to improve the prognosis of these patients, AVR could be considered before the occurrence of severely elevated PAP

Cardiac tamponade related to a coronary injury by a pericardial calcification: an unusual complication

<p>Abstract</p> <p>Background</p> <p>Cardiac tamponade is a rare but severe complication of pericardial effusion with a poor prognosis. Prompt diagnosis using transthoracic echocardiography allows guiding initial therapeutic management. Although etiologies are numerous, cardiac tamponade is more often due to a hemopericardium. Rarely, a coronary injury may result in such a hemopericardium with cardiac tamponade. Coronary artery aneurysm are the main etiologies but blunt, open chest trauma or complication of endovascular procedures have also been described.</p> <p>Case presentation</p> <p>A 83-year-old hypertensive man presented for dizziness and hypotension. The patient had oliguria and mottled skin. Transthoracic echocardiography disclosed a circumferential pericardial effusion with a compressed right atrium, confirmed by contrast-enhanced thoracic CT scan. A pig-tail catheter allowed to withdraw 500 mL of blood, resulting in a transient improvement of hemodynamics. Rapidly, recurrent hypotension prompted a reoperation. An active bleeding was identified at the level of the retroventricular coronary artery. The pericardium was thickened with several "sharping" calcified plaques in the vicinity of the bleeding areas. On day 2, vasopressors were stopped and the patient was successfully extubated. Final diagnosis was a spontaneous cardiac tamponade secondary to a coronary artery injury attributed to a "sharping"calcified pericardial plaque.</p> <p>Conclusion</p> <p>Cardiac tamponade secondary to the development of a hemopericardium may develop as the result of a myocardial and coronary artery injury induced by a calcified pericardial plaque.</p

Echocardiographie de stress sous dobutamine (validation de l'expérience de Limoges)

LIMOGES-BU Médecine pharmacie (870852108) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Thrombose de stent (étude monocentrique à Limoges 2005 à 2008)

La thrombose de stent est une complication peu fréquente de l angioplastie coronaire. Elle est associée à un fort taux de mortalité (20 à 40%) et d infarctus (70%). Une définition standardisée a été proposée par l American Research Consortium en 2007. Le but de cette étude était de décrire la population des patients ayant présenté une thrombose de stent au CHU de Limoges et de comparer nos données aux données de la littérature. L objectif secondaire de cette étude était de comparer les thromboses de stents précoces et les thromboses de stents tardives en termes d incidence, de facteurs prédictifs et de pronostic. Entre 2005 et 2008, 57 patients ont présenté une TS concernant des stents implantés dan ce centre. Les critères retenus pour la définition des cas sont ceux de l ACR. 45 patients ont présenté une TS précoce et 12 patients ont présenté une TS tardive ou très tardive. Nos résultats sont comparables aux données de la littérature en termes d incidence et de pronostic. L incidence est de 2, 06 % à 3 ans. Il n y a pas de différence entre les types de stents. La mortalité à 1 an est de 17,5%. Les profils de patients sont différents entre TS précoces et tardives. La TS est associée à un taux de décès significativement plus important par rapport à la TS tardive. Nos données sont comparables en termes d incidence et de pronostic aux données de la littérature. D autres études prospectives devront confirmer la différence de survie dans les deux groupes en utilisant ce critère comme critère principal.LIMOGES-BU Médecine pharmacie (870852108) / SudocSudocFranceF

Intérêt de l'échographie endocoronaire en cardiologie interventionnelle

LIMOGES-BU Médecine pharmacie (870852108) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Prognosis importance of low flow in aortic stenosis with preserved LVEF

International audienceAIMS:Previous studies using echocardiography suggested that a low flow (LF) defined as an indexed stroke volume (SVi) 50%) and severe AS (valve area ≤1 cm(2)) without other valvular heart disease underwent cardiac catheterisation. The long-term overall mortality was assessed as the primary end-point.RESULTS:Mean age was 74±8 years, 58% were men, 46% had coronary artery disease and mean LVEF was 72±10%. Low SVi was found in 27% (n=210) of patients with AS. As compared with patients with normal SVi, those with low SVi were significantly older (p<0.0001) with higher rate of atrial fibrillation (p<0.0001). Additionally, they had lower LVEF (p=0.046), aortic valve area (p<0.0001), mean pressure gradient (p<0.0001), systemic arterial compliance (p<0.0001) and higher systemic vascular resistances (p<0.0001). Eight-year survival was significantly reduced in patients with low SVi as compared with those with normal SVi (51±5% vs 67±3%; p<0.0001). After adjustment for all other risk factors, reduced SVi was independently associated with long-term mortality (HR=1.45, 95% CI 1.1 to 2.1; p=0.048).CONCLUSIONS:In patients with severe AS and preserved LVEF, LF, as assessed using cardiac catheterisation is frequent, and is an independent predictor of mortality. Consequently, the measurement of SVi should be systematically included in the assessment of these patients

Prognostic impact of global left ventricular hemodynamic afterload in severe aortic stenosis with preserved ejection fraction

International audienceINTRODUCTION:Global left ventricular (LV) afterload as assessed by valvulo-arterial impedance (Zva), may be an independent predictor of mortality in patients with severe aortic stenosis (AS) and preserved LV ejection fraction (LVEF). However, its quantification using echocardiography may be subject to error measurement. We aimed to determine the prevalence and impact on long-term survival of high Zva, purposely measured by cardiac catheterization.METHODS AND RESULTS:676 patients with preserved LVEF and severe AS without other valvular heart diseases underwent cardiac catheterization. Zva was derived from catheterization and calculated as follows: mean aortic gradient+systolic blood pressure/indexed LV stroke volume. Zva was considered high when >5mmHg/mL/m(2) based on previous studies. Overall, high Zva was found in 42% of all AS patients. Four-year survival and 8-year survival were significantly reduced in patients with high Zva (74±3% and 57±4%) as compared to those with low Zva (85±2% and 74±3%; p=0.002). After adjustment for all other risk factors, Zva was independently associated with reduced long-term survival (hazard ratio [HR]=1.47 95% CI: 1.04-2.09; p=0.029). Of interest, high Zva remained associated with reduced survival as compared to low Zva, in patients with normal LV stroke volume, but was no longer significant in low flow patients (p=0.98).CONCLUSION:High Zva, estimated invasively in our study, is frequent in patients with severe AS, and appears as a robust and independent predictor of survival. Zva should be used as an additional parameter for risk stratification of severe AS, more particularly in patients with normal flow

6- Versus 24-Month Dual Antiplatelet Therapy After Implantation of Drug-Eluting Stents in Patients Nonresistant to Aspirin

International audienc