Impact of cone-beam computed tomography for the identification and management of an oral portal of entry in patients with infective endocarditis. A Delphi study

Infective endocarditis (IE) is a rare and life-threatening disease. Cutaneous portal of entry (POE) is predominant for IE, but an oral POE is the second most frequent source. Thus looking for and treating an oral POE in IE patients is of critical importance in order to reduce the risk of IE relapse or recurrence. The objectives of this study were: 1) To reach a consensus on decision-making following the detection of an oral POE on cone-beam computed tomography (CBCT) while they were not identified using the current recommended approach in IE patients (oral examination and orthopantomogram: OPT). 2) To determine whether this consensus differs when regarding the microbiology of IE. Twenty oral or maxillofacial surgeons participated to this Delphi study. The questionnaire was based on five radiological cases (OPT and matching CBCT) with two scenarios according to the objectives of detecting oral POE in an IE patient (curative in case of oral causative microorganism, and preventive if not) and different therapeutic approaches (surgical or conservative treatment, no treatment) for each of them. Consensus was defined as an agreement rate of ?75%. The response rate was?85%. After four rounds, consensus was achieved for all proposals. CBCT changed the decision-making of experts in four cases. In one case, the decision was influenced by the IE microbiology toward a more radical approach in case of oral causative microorganism. In IE patients, CBCT changed markedly the decision-making of experts by eradicating more oral POE than when using OPT. This could reduce the risk of IE relapse and recurrence

Asymptomatic Severe and Moderate Aortic Stenosis:Time for Appraisal of Treatment Indications

Over the last decades, we have witnessed considerable improvements in diagnostics and risk stratification of patients with significant aortic stenosis (AS), paralleled by advances in operative and anesthetic techniques. In addition, accumulating evidence points to the potential benefit of early valve replacement in such patients prior to the onset of symptoms. In parallel, interventional randomized trials have proven the benefit of transcatheter aortic valve replacement in comparison to a surgical approach to valve replacement over a broad risk spectrum in symptomatic patients with AS. This article reviews contemporary management approaches and scrutinizes open questions regarding timing and mode of intervention in asymptomatic patients with severe AS. We also discuss the challenges surrounding the management of symptomatic patients with moderate AS as well as emerging dilemmas related to the concept of a life-long treatment strategy for patients with AS.</p

Impact of Degree of Commissural Opening After Percutaneous Mitral Commissurotomy on Long-Term Outcome

ObjectivesWe sought to evaluate the prognostic value of the degree of commissural opening (CO) on outcome.BackgroundCommissural opening is the main mechanism by which the mitral valve area (MVA) increases after percutaneous mitral commissurotomy (PMC) but its impact on long-term outcome has never been evaluated.MethodsOf 1,024 consecutive patients with severe MS who underwent PMC, degree of CO was prospectively evaluated in 875 patients (age 48 ± 13 years, female 83%, New York Heart Association (NYHA) functional class III/IV 75%) with good immediate PMC results (MVA ≥1.5 cm2 and no mitral regurgitation >2/4). These 875 patients were divided into 3 groups: both commissures only partially opened or not split (Group 1, n = 189), 1 commissure completely split (Group 2; n = 459), and both commissures completely split (Group 3; n = 227). During a follow-up of 55 ± 28 months, following clinical end points were collected: death, cardiovascular death, need for mitral valve surgery or repeat dilation, and NYHA functional class.ResultsBefore PMC, patients in Group 1 were older, more often in NYHA functional class III/IV, but MVA and mean gradient were not different (p ≥ 0.50). Immediately after PMC, there were significant differences between groups with regard to mean gradient (Group 1, 5.1 ± 2.1 mm Hg; Group 2, 4.5 ± 1.7 mm Hg; Group 3, 4.0 ± 1.6 mm Hg; p < 0.0001) and MVA (Group 1, 1.8 ± 0.2 cm2; Group 2, 1.9 ± 0.2 cm2; Group 3, 2.1 ± 0.3 cm2; p < 0.0001). The 10-year rate of good functional results (survival without need for mitral surgery or repeat dilation and NYHA functional class I or II at last follow-up) was significantly higher in Group 3 (76 ± 5%) than in Groups 1 and 2 (39 ± 8% and 57 ± 11%, respectively; p < 0.0001). In multivariable analysis, either the degree of CO or the MVA was an independent predictor of good late functional results (p < 0.05).ConclusionsComplete CO is associated with larger MVA, smaller gradients, and functional improvement. The degree of CO provides important prognostic information and thus should be systematically evaluated during and after PMC and considered as a complementary measure of the procedural success in addition to the MVA, not always easy to assess

Contemporary Presentation and Management of Valvular Heart Disease The EURObservational Research Programme Valvular Heart Disease II Survey

Background: Valvular heart disease (VHD) is an important cause of mortality and morbidity and has been subject to important changes in management. The VHD II survey was designed by the EURObservational Research Programme of the European Society of Cardiology to analyze actual management of VHD and to compare practice with guidelines. Methods: Patients with severe native VHD or previous valvular intervention were enrolled prospectively across 28 countries over a 3-month period in 2017. Indications for intervention were considered concordant if the intervention was performed or scheduled in symptomatic patients, corresponding to Class I recommendations specified in the 2012 European Society of Cardiology and in the 2014 American Heart Association/American College of Cardiology VHD guidelines. Results: A total of 7247 patients (4483 hospitalized, 2764 outpatients) were included in 222 centers. Median age was 71 years (interquartile range, 62-80 years); 1917 patients (26.5%) were >= 80 years; and 3416 were female (47.1%). Severe native VHD was present in 5219 patients (72.0%): aortic stenosis in 2152 (41.2% of native VHD), aortic regurgitation in 279 (5.3%), mitral stenosis in 234 (4.5%), mitral regurgitation in 1114 (21.3%; primary in 746 and secondary in 368), multiple left-sided VHD in 1297 (24.9%), and right-sided VHD in 143 (2.7%). Two thousand twenty-eight patients (28.0%) had undergone previous valvular intervention. Intervention was performed in 37.0% and scheduled in 26.8% of patients with native VHD. The decision for intervention was concordant with Class I recommendations in symptomatic patients with severe single left-sided native VHD in 79.4% (95% CI, 77.1-81.6) for aortic stenosis, 77.6% (95% CI, 69.9-84.0) for aortic regurgitation, 68.5% (95% CI, 60.8-75.4) for mitral stenosis, and 71.0% (95% CI, 66.4-75.3) for primary mitral regurgitation. Valvular interventions were performed in 2150 patients during the survey; of them, 47.8% of patients with single left-sided native VHD were in New York Heart Association class III or IV. Transcatheter procedures were performed in 38.7% of patients with aortic stenosis and 16.7% of those with mitral regurgitation. Conclusions: Despite good concordance between Class I recommendations and practice in patients with aortic VHD, the suboptimal number in mitral VHD and late referral for valvular interventions suggest the need to improve further guideline implementation

Contemporary Management of Severe Symptomatic Aortic Stenosis

There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS).This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey.Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention.A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age-adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001).A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians

Data standards for transcatheter aortic valve implantation: the European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart)

Funding: European Society of Cardiology.publishersversionepub_ahead_of_prin