Ischaemic mitral regurgitation: pathophysiology, outcomes and the conundrum of treatment.

peer reviewedIschaemic mitral regurgitation is a frequent complication of left ventricular global or regional pathological remodelling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces (papillary muscles displacement leading to a more apical position of the leaflets and their coaptation point) and reduced closing forces (reduced contractility, dyssynchrony of the papillary muscles, intra-left ventricular dyssynchrony). Although mitral regurgitation has an unloading effect and reduces impedance, the volume overload begets further left ventricular dilatation, increases ventricular wall stress leading to worsened performance. Ischaemic mitral regurgitation is characteristically dynamic: its severity may vary with haemodynamic conditions. Both the severity of ischaemic mitral regurgitation and its dynamic component worsen prognosis. There are numerous possible treatment modalities, but the management of the individual patient remains difficult. Medical therapy is mandatory; revascularization procedures are frequently not sufficient to reduce mitral regurgitation; the role of combined surgical therapy by mitral valve repair is not yet defined in the absence of large randomized trial. Some patients are good candidates for cardiac resynchronization therapy that may reduce the amount of regurgitation. New therapeutic targets are under investigation

Exercise testing in asymptomatic severe aortic stenosis.

peer reviewedThe management and the clinical decision making in asymptomatic patients with aortic stenosis are challenging. An "aggressive" management, including early aortic valve replacement, is debated in these patients. However, the optimal timing for surgery remains controversial due to the lack of prospective data on the determinants of aortic stenosis progression, multicenter studies on risk stratification, and randomized studies on patient management. Exercise stress testing with or without imaging is strictly contraindicated in symptomatic patients with severe aortic stenosis. Exercise stress test is now recommended by current guidelines in asymptomatic patients and may provide incremental prognostic value. Indeed, the development of symptoms during exercise or an abnormal blood pressure response are associated with poor outcome and should be considered as an indication for surgery, as suggested by the most recently updated European Society of Cardiology 2012 guidelines. Exercise stress echocardiography may also improve the risk stratification and identify asymptomatic patients at higher risk of a cardiac event. When the test is combined with imaging, echocardiography during exercise should be recommended rather than post-exercise echocardiography. During exercise, an increase >18 to 20 mm Hg in mean pressure gradient, absence of improvement in left ventricular ejection fraction (i.e., absence of contractile reserve), and/or a systolic pulmonary arterial pressure >60 mm Hg (i.e., exercise pulmonary hypertension) are suggestive signs of advanced stages of the disease and impaired prognosis. Hence, exercise stress test may identify resting asymptomatic patients who develop exercise abnormalities and in whom surgery is recommended according to current guidelines. Exercise stress echocardiography may further unmask a subset of asymptomatic patients (i.e., without exercise stress test abnormalities) who are at high risk of reduced cardiac event free survival. In these patients, early surgery could be beneficial, whereas regular follow-up seems more appropriate in patients without echocardiographic abnormalities during exercise

Inflammation and Atherosclerosis: State of the Art in 2004-2005

peer reviewedInflammation plays a pivotal role in atherosclerosis; being present in all steps of the pathology, from initiation to the progression of the lesions to the development of vulnerable plaques and clinical destabilisation. Therefore, systemic markers of inflammation have emerged to predict future cardiovascular events in patients initially admitted for unstable syndromes, but also in healthy subjects. These markers can identify high risk patients and they are used to adapt ideal treatment to the patient's profile. The implication of the inflammation process in the treatment strategies is described in the last part of the article

Exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation

BACKGROUND: Current guidelines recommend mitral valve surgery for asymptomatic patients with severe degenerative mitral regurgitation and preserved left ventricular systolic function when exercise pulmonary hypertension (PHT) is present. However, the determinants of exercise PHT have not been evaluated. The aim of this study was to identify the echocardiographic predictors of exercise PHT and the impact on symptoms. METHODS AND RESULTS: Comprehensive resting and exercise transthoracic echocardiography was performed in 78 consecutive patients (age, 61+/-13 years; 56% men) with at least moderate degenerative mitral regurgitation (effective regurgitant orifice area =43+/-20 mm(2); regurgitant volume =71+/-27 mL). Exercise PHT was defined as a systolic pulmonary arterial pressure (SPAP) >60 mm Hg. Exercise PHT was present in 46% patients. In multivariable analysis, exercise effective regurgitant orifice was an independent determinant of exercise SPAP (P56 mm Hg) was more accurate than resting PHT (SPAP >36 mm Hg) in predicting the occurrence of symptoms during follow-up (P=0.032). CONCLUSIONS: Exercise PHT is frequent in patients with asymptomatic degenerative mitral regurgitation. Exercise mitral regurgitation severity is a strong independent predictor of both exercise SPAP and exercise PHT. Exercise PHT is associated with markedly low 2-year symptom-free survival, emphasizing the use of exercise echocardiography. An exercise SPAP >56 mm Hg accurately predicts the occurrence of symptoms.Peer reviewe

Skin capacitance imaging, a new technique for investigating the skin surface.

Thanks to the recently introduced silicone image sensor technology, skin capacitance imaging has now been made possible. The dedicated device is called SkinChip. This method is easy to handle and provides information about the skin microrelief, the level of stratum corneum hydration and the sweat gland activity. The apparatus sees and measures these parameters with a 50 microm resolution. A series of conditions have been explored using skin capacitance imaging. This review summarizes relevant findings about regional variability on the body, changes occurring with ageing, effects of a hydrating formulation, reactivity kinetics of corneocytes to surfactants, acne and skin pores characteristics, as well as hyperkeratotic dermatoses and tumours

Functional mitral regurgitation: Signification

peer reviewedFunctional mitral regurgitation is frequent in heart failure patients. It is characteristically dynamic and sensitive to changes in ventricular size, shape, and loading, which increase leaflet tethering and/or the reduced mitral valve closing force. In heart failure patients, exercise-induced increases in MR severity contribute to a limitation of exercise capacity and convey a poor prognosis. Such dynamic MR changes during exercise are usually accompanied by increases in systolic pulmonary artery pressure and are related to changes in mitral valve configuration and mitral apparatus geometry at both ends of the tethered leaflets and heterogeneous activation sequence of the basal left ventricular walls, namely dynamic left ventricular dyssynchrony

How I treat ... by optimizing the blockade of renin-angiotensin-aldosterone system

peer reviewedThe blockade of the renin-angiotensin-aldosterone system (RAAS) has been shown to be useful, or even mandatory, in the management of arterial hypertension, congestive heart failure, post-myocardial infarction and nephropathy with albuminuria, due to diabetes or not. Such blockade can be obtained with an angiotensin converting enzyme inhibitor, a specific antagonist of angiotensin II AT1 receptors and/or recently a direct inhibitor of renin such as aliskiren. Various studies have demonstrated the advantage of optimising RAAS blockade in order to benefit of the best cardiorenal protection. The present article describes the various modalities to optimize the RAAS blockade, either by using a maximal dosage of a monotherapy, or by choosing a double inhibition of RAAS. New prospects for the RAAS blockade will be also briefly considered.Le blocage du système rénine-angiotensine-aldostérone (SRAA) s'est avéré très utile, voire incontournable, dans le traitement de l'hypertension artérielle, de la décompensation cardiaque, du post-infarctus et de la néphropathie albuminurique, diabétique ou non. Ce blocage peut être réalisé par un inhibiteur de l'enzyme de conversion de l'angiotensine, un antagoniste des récepteurs AT1 de l'angiotensine II et/ou, récemment, un inhibiteur direct de la rénine, comme l'aliskiren. Diverses études ont montré l'intérêt d'optimiser le blocage du SRAA pour bénéficier des meilleurs effets de protection cardio-rénale. Cet article décrit les modalités pour obtenir un blocage optimal du SRAA, soit en recourant à un dosage maximal d'une monothérapie, soit en faisant appel à une double inhibition pharmacologique du SRAA. De nouvelles perspectives concernant le blocage du SRAA seront également évoquées

Echocardiography in the emergency roon: non-invasive imaging.

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