120 Superiority of CT scan over transthoracic echocardiography in predicting aortic regurgitation after TAVI

BackgroundParavalvular aortic regurgitation (AR) occurs in up to 86% of patients undergoing Transcatheter Aortic Valve Implantation (TAVI). Its prevalence remains unchanged after one year follow-up but its determinants are unclear. We sought to evaluate the impact of annulus measurement by transthoracic echocardiography (TTE) and by CT scan on the occurrence of AR.MethodsThe study included 43 symptomatic patients (83±8 years, 72% in NYHA≥III) with severe aortic stenosis [0.76±0.19cm2, mean gradient 42±14mmHg] who underwent TAVI using CoreValve® LLC Percutaneous Aortic Valve Implantation System, Medtronic, Minneapolis USA. Left ventricular outflow tract (LVOT) area was computed from LVOT diameter (21±2mm) by TTE using a spherical model and from CT using an ellipsoidal model according to the larger (25±3mm) and the smaller outflow tract diameters (22±3mm). These data were compared to the prosthesis area and the occurrence of AR after TAVI.ResultsIn patients with AR greater or equal to 2/4 (32%), LVOT area measured by CT was significantly greater as compared to patients with no or mild AR (478±65mm 2 vs. 411±85mm2, p=0.009). Furthermore, the difference between actual prosthesis area and LVOT area measured by CT scan was significantly smaller (113±55 vs. 171±67, p=0.009) in patients with significant AR (≥2/4) after TAVI. In contrast, LVOT area from TTE did not correlate with AR severity.ConclusionCT scan is more accurate than TTE for calculating LVOT area for prosthesis sizing before TAVI in order to avoid post-implantation AR

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

Facteurs prédictifs de stimulation cardiaque définitive après implantation d'une bioprothèse aortique par voie percutanée de type corevalve

TOURS-BU Médecine (372612103) / SudocSudocFranceF

Évaluation fonctionnelle des valvulopathies par écho-Doppler trans-thoracique, hémodynamique Doppler de stress et dosages neuro-hormonaux

L'ensemble des travaux de recherche clinique menés pour cette Thèse évalue des méthodes d'analyse standardisée en écho-Doppler cardiaque, des paramètres hémodynamiques en échographie de stress ou des dosages neuro-hormonaux, afin de valider de nouveaux critères décisionnels dans le domaine des maladies valvulaires cardiaques. Le premier axe de recherche est le rétrécissement aortique calcifié (RAC) avec dysfonction ventriculaire gauche (VG) et bas débit cardiaque. Nous avons démontré que l'étude de la réserve contractile VG par échographie dobutamine est un facteur indépendant du risque opératoire et de la survie à long terme. Toutefois, malgré sa forte influence sur la mortalité opératoire, l'absence de réserve contractile ne permet pas de récuser formellement un patient pour la chirurgie, compte tenu du fait qu'elle n'obère pas l'amélioration fonctionnelle postopératoire. Dans un deuxième temps, nous avons étudié l'intérêt des dosages neuro-hormonaux (B-type Natriuretic Peptide, BNP) en cas de sténose aortique. Nos résultats montrent que le dosage du BNP est utile pour séparer les patients symptomatiques des asymptomatiques et que le taux de BNP a une forte valeur pronostique pour la mortalité à moyen terme. Concernant l'insuffisance mitrale, nous avons démontré que grâce à l'amélioration des techniques d'imagerie et à une expertise fondée sur la confrontation systématique avec les données chirurgicales, l'analyse fonctionnelle de l'IM et la faisabilité de la plastie mitrale sont actuellement fiables par échographie transthoracique dans la plupart des cas, sans recours nécessaire à l'échographie transœsophagienne, hormis dans les cas d'endocardite.The studies included in this work in the field of cardiac valve diseases, sought to assess new parameters that might be helpful for clinical decision making. The following techniques were assessed: standardized method for functional analysis of mitral regurgitation (MR) by transthoracic echocardiography (TTE), dobutamine stress hemodynamics and cardiac biomarkers for severe aortic stenosis (AS). In the setting of low-gradient AS, we have demonstrated that left ventricular (LV) contractile reserve assessed by dobutamine hemodynamics has the potential to stratify operative risk and to predict long-term outcome. However, given that postoperative improvement in LV ejection fraction is not related to preoperative LV contractile reserve, surgery should not be contraindicated on the sole basis of exhausted contractile reserve. In patients with severe AS, we evaluated the relation between B-type Natriuretic Peptide (BNP) serum levels and symptoms. We found that BNP levels were elevated in the presence of symptoms and increased with NYHA functional class. Furthermore, BNP level was a strong independent predictor for cardiovascular death by multivariable analysis adjusted to age and NYHA functional class. Finally, we sought to assess the value of TTE using standardized imaging planes for the functional analysis of MR as well as for postoperative outcome implications. We found that, in experienced hands, functional assessment of MR by TTE can predict accurately valve repairability and has a strong influence on postoperative outcome. Thus, in most cases preoperative transesophageal echocardiography (TEE) is not mandatory, provided intraoperative TEE is performed.PARIS12-CRETEIL BU Multidisc. (940282102) / SudocPARIS-BIUP (751062107) / SudocSudocFranceF

DETECTION DU SEUIL ISCHEMIQUE EN ECHOCARDIOGRAPHIE DE STRESS PENDANT UN EXERCICE PHYSIQUE

PARIS-BIUM (751062103) / SudocCentre Technique Livre Ens. Sup. (774682301) / SudocSudocFranceF