0327: Echocardiography improves the risk prediction of peri-operative outcomes in patients undergoing coronary bypass surgery? A prospective study

ObjectiveTo assess the performance of transthoracic echocardiographic (TTE) parameters to predict operative mortality and morbidity in patients undergoing coronary artery bypass grafting (CABG) and to compare their pronostic value to that obtained by the Society of Thoracic Surgeon (STS) score.Materiels and MethodsWe prospectively collected the clinical and biological data required to calculate the STS score in patients hospitalized for CABG. A preoperative TTE was performed for each patient. Primary endpoint was 30-days mortality or major morbity (i.e. stroke, renal failure, prolonged ventilation, deep sternal wound infection, reoperation) as defined by the STS. Secondary end-point was prolonged hospitalization>14 days.Results172 patients were included (mean age 66.1±10.2 years, 12.2% were women). The primary end-point occurred in 33 patients (19.2%) and 28 patients (16.3%) had a prolonged hospital stay. Independent predictive factors for the primary end-point were an increased left atrial volume (>31mL/m2) (OR=3.186, IC 95%=1.266; 8.015, p=0.014) and a decreased tricuspid annular plane systolic excursion (TAPSE<20mm) (OR=2.709, IC 95% 1.144; 6.410, p=0.023). The addition of these two parameters to the STS score improved significantly the model performance (figure) with a better risk prediction (Integrated Discrimination Improvement=7.44).ConclusionIn patients undergoing CABG, preoperative TTE is mandatory as it provides an additional prognostic value to the STS score.Abstract 0327 - Figure: Incremental prognostic value of TT

Impact of Prosthesis-Patient Mismatch on Long-Term Survival After Aortic Valve Replacement Influence of Age, Obesity, and Left Ventricular Dysfunction

ObjectivesThis study was designed to evaluate the effect of valve prosthesis-patient mismatch (PPM) on late survival after aortic valve replacement (AVR) and to determine if this effect is modulated by patient age, body mass index (BMI), and pre-operative left ventricular (LV) function.BackgroundWe recently reported that PPM is an independent predictor of operative mortality after AVR, particularly when associated with LV dysfunction.MethodsThe indexed valve effective orifice area (EOA) was estimated in 2,576 patients having survived AVR and was used to define PPM as not clinically significant if it was >0.85 cm2/m2, as moderate if >0.65 and ≤0.85 cm2/m2, and severe if ≤0.65 cm2/m2.ResultsAfter adjustment for other risk factors, severe PPM was associated with increased late overall mortality (hazard ratio [HR]: 1.38; p = 0.03) and cardiovascular mortality (HR: 1.63; p = 0.0006) in the whole cohort. Severe PPM was also associated with increased overall mortality in patients <70 years old (HR: 1.77; p = 0.002) and in patients with a BMI <30 kg/m2 (HR: 2.1; p = 0.006), but had no impact in older patients or in obese patients. Moderate PPM was a predictor of mortality in patients with LV ejection fraction <50% (HR: 1.21; p = 0.01), but not in patients with preserved LV function.ConclusionsModerate PPM is associated with increased late mortality in patients with LV dysfunction, but with normal prognosis in those with preserved LV function. Notwithstanding the previously demonstrated deleterious effect of severe PPM on early mortality, this factor appears to increase late mortality only in patients <70 years old and/or with a BMI <30 kg/m2 or an LV ejection fraction <50%

Metabolic syndrome increases operative mortality in patients undergoing coronary artery bypass grafting surgery

OBJECTIVES: The aim of this study was to determine the impact of the metabolic syndrome (MS) on operative mortality after a coronary artery bypass grafting surgery (CABG). BACKGROUND: Diabetes and obesity are highly prevalent among patients undergoing CABG. However, it remains unclear whether these factors have a significant impact on operative mortality after this procedure. We hypothesized that the metabolic abnormalities associated with MS could negatively influence the operative outcome of CABG surgery. METHODS: We retrospectively analyzed the data of 5,304 consecutive patients who underwent an isolated CABG procedure between 2000 and 2004. Of these 5,304 patients, 2,411 (46%) patients met the National Cholesterol Education Program-Adult Treatment Panel III criteria for MS. The primary end point was operative mortality. RESULTS: The operative mortality after CABG surgery was 2.4% in patients with MS and 0.9% in patients without MS (p < 0.0001). The MS was a strong independent predictor of operative mortality (relative risk 3.04 [95% confidence interval (CI) 1.73 to 5.32], p = 0.0001). After adjusting for other risk factors, the risk of mortality was increased 2.69-fold (95% CI 1.43 to 5.06; p = 0.002) in patients with MS and diabetes and 2.36-fold (95% CI 1.26 to 4.41; p = 0.007) in patients with MS and no diabetes, whereas it was not significantly increased in the patients with diabetes and no MS. CONCLUSIONS: This is the first study to report that MS is a highly prevalent and powerful risk factor for operative mortality in patients undergoing a CABG surgery. Thus, interventions that could contribute to reduce the prevalence of MS in patients with coronary artery disease or that could acutely modify the metabolic perturbations of MS at the time of CABG might substantially improve survival in these patient

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

2016 ESC Position Paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines: The Task Force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC)

Peer reviewe

Les déterminants métaboliques de développement et de progression de la sténose aortique calcifiée

La sténose aortique calcifiée (SA) également dite dégénérative est la pathologie la plus fréquente en Occident après l'ypertension artérielle et la maladie coronaire ; sa prévalence devrait augmenter considérablement d'ici 2020 à cause du vieillissement de la population. Les travaux de ces dernières années ont modifié notre vue sur la SA puisqu'ils ont démontré qu'il s'agit d'une maladie inflammatoire ayant d'importantes similarités épidémiologiques, quant aux facteurs de risque cardiovasculaires, et histologiques avec l'athérosclérose vasculaire. Par conséquent, il est possible théoriquement de modifier l'évolution naturelle de cette maladie par des interventions diététiques et/ou pharmacologiques retardant ou évitant peut-être la chirurgie. Mais pour cela, il est nécessaire de comprendre les déterminants métaboliques qui contribuent potentiellement au développement et à la progression de la SA. Un article publié récemment par nos collaborateurs a montré qu'un régime riche en matières grasses et en sucres rapides chez la souris induisait une SA. Par la suite, notre équipe a pu montrer que les sujets humains porteurs de SA modérée et/ou sévère et ayant un syndrome métabolique (SM), avaient une progression hémodynamique de leur SA deux fois plus rapide que les patients sans SM. Ce travail nous a donc incité à tenter de déterminer quelles sont les perturbations métaboliques sous-jacentes qui pourraient expliquer cette association. Dans le premier article, nous avons démontré qu'il existait une association significative entre le pourcentage de particles LDL petites et denses et la progression hémodynamique de la SA ainsi qu'une corrélation entre la présence de ces petites particles et le dégré d'inflammation de la valve aortique explantée au moment de la chirurgie de remplacement de la valve aortique. L'inflammation et le degré de remodelage étaient dans ce travail eux-mêmes corrélés au degré d'infiltration de la valve par les LDL oxydées. Dans le second article, nous avons montré qu'une autre anomalie associée au SM et à l'obésité viscérale : l'hypoadiponectinémie était associée de façon significative à la progression hémodynamique de la SA ; de plus, le taux d'adiponectine sanguin était inversement corrélé au degré d'inflammation valvulaire ainsi qu'au nombre de néo vaisseaux, ce qui pourrait expliquer l'association avec la progression de la SA. Enfin dans le troisième article, nous avons trouvé que le taux de résistine, une autre adipokine liée à l'inflammation et à l'athérosclérose, était corrélé au degré d'inflammation et de calcification valvulaire chez les sujets âgés opérés pour une SA. Ces résultats permettent de confirmer qu'il existe bel et bien des relations significatives entre des anomalies métaboliques et la SA calcifiée, qu'il ne s'agit plus d'une maladie dégénérative liée uniquement au vieillissement et à l'usure de la valve aortique par le stress mécanique qui lui est imposé, mais qu'il s'agit d'une pathologie reliée à un processus athérosclérotique actif. En particulier, nous avons démontré que certaines perturbations métaboliques liées à l'obésité viscérale sont impliquées dans la progression de la SA. Par conséquent, des modifications de notre alimentation et de notre activité physique et/ou des interventions médicamenteuses pourraient altérer l'histoire naturelle et la progression de la SA.Aortic stenosis (AS), is the most frequent disease in western countries after hypertension and coronary artery disease. Due to the aging of the population, its prevalence will dramatically increase within the next decade. Previous studies have shown that AS is an inflammatory disease and it has multiple similarities with vascular atherosclerosis. Therefore, it may be possible to alter the natural evolution of this disease using dietary and/or pharmacological interventions, avoiding or delaying surgery. It is crucial thus, to determine the metabolic factors that potentially contribute to the development and the progression of AS. In a recent experimental animal study, Drolet et al. were able to induce true AS in a wild type mouse that received a high fat and carbohydrate diet. Briand et al. from the same team, also demonstrated in a human study that patients with moderate to severe AS and presenting a metabolic syndrome (MS) had a 2 fold more hemodynamic progression of AS than patients without MS. Therefore, the aim of our present project was to investigate the potential metabolic factors that may explain the association between the MS and the progression of AS. In the first article of this project, we reported a significant association between the percentage of the small and dense LDL particles and the hemodynamic progression of AS; also a significant correlation was found between these small LDL particles and the inflammatory activity within the aortic valve explanted at the time of aortic valve replacement. In this study, the inflammatory activity and the remodelling score of the AV also correlated with the accumulation of oxidized LDL in the AV. In the second article, we demonstrated that low plasma level of adiponectin were significantly associated with the hemodynamic progression of AS. Moreover, adiponectin level was inversely correlated with the valvular inflammatory activity. These findings may explain the association between MS and the rapid AS progression. Finally, in the third article, we found that plasma resistin level was correlated with valvular calcification and inflammation of the AV in elderly patients with AS. These results showed clearly a significant relations between the metabolic disturbances and calcified AS. Thus, AS should not be considered as a simple degenerative disease related to aging and to the wear and shear stress. It is a true atherosclerotic process. We particularly demonstrated that some metabolic disturbances related to the visceral obesity may play an important role in the hemodynamic AS progression.TOURS-BU Médecine (372612103) / SudocSudocFranceF