107 Care management of heart failure in elderly patients in France. Results from the DEVENIR study

RationaleThe part of elderly patients (pts) in heart failure (HF) population is growing. They might pose specific problems due to the greater proportion of HF with preserved LVEF, more frequent comorbidities or contra-indications to recommended HF treatment.Objectivesto describe the care management of pts > 80-year treated for HF in France.MethodsCross sectional observational survey with retrospective collection of data at hospital discharge. Pts must have been diagnosed with CHF and have been hospitalised for CHF within the previous 18 months. Pts are classified according to the LVEF at hospital discharge.Results412 French outhospital cardiologists entered 1 452 pts meeting the inclusion criteria. FEVG at hospital discharge was known for 1408 pts. 355 (25%) were more than 80-year-old. Management care at hospital discharge according to age and LVEF is detailed below.LVEF < 40%LVEF 40-50%LVEF > 50%TotalAge>80ACEI/ARB84%81%80%82%*BB71%67%40%†,‡62%*Loop diuretics92%85%85%88%Spironolactone/eplerenone26%20%18%22%*Digoxin20%15%29%21%*Calcium antagonists10%14%37%†,‡18%Anticoagulants49%45%51%49%*Age≤80ACEI/ARB93%93%85%†,‡92%BB79%78%76%79%Loop diuretics90%82%79%†,§86%Spironolactone/eplerenone35%21%25%†,§30%Digoxin16%15%16%15%Calcium antagonists9%19%21%†,§13%Anticoagulants42%39%39%41%†p<0.05 for comparisons between LVEF > 50% and LVEF<40%;‡p<0.05 for comparisons between LVEF>50% and LVEF between 40% and 50%;§: p<0.05 for comparisons between LVEF<40% and LVEF between 40% and 50%;*p<0.05 for comparisons between > 80 and ≤ 80 years old adjusted for LVEF.ConclusionBB, ACEI/ARB, spironolactone/eplerenone are less often prescribed in elderly patients contrasting with digoxin and anticoagulants prescription. These differences persist after adjustment on LVEF

088 Prescription of beta blockers at hospital discharge and beyond, in patients with heart failure. Results from the DEVENIR study

RationaleBeta blockers are a corner stone treatment of heart failure (HF) in patients with altered systolic function (LVEF<40%). Guidelines are less clear for HF patients with preserved systolic function (LVEF>50%) or for patients belonging to the “grey zone” (LVEF 40-50%).Objectivesto describe the prescription rate of beta-blockers in HF patients.MethodsCross sectional observational survey with retrospective collection of data at hospital discharge. Patients must have been diagnosed with CHF and have been hospitalised for CHF within the previous 18 months. Patients are classified according to the LVEF at hospital discharge.Results1 452 patients were included by 412 French outhospital cardiologists. 1137 with known LVEF at hospital discharge have had at least one visit by the cardiologist between hospital discharge (mean delay 5.76±4.51 months). In a multivariate model, BB prescription was more frequent in HF from ischemic origin (OR=1.39) or with dilated cardiomyopathy (OR=1.44) and less frequent in older patients (OR=0.97 per year) and in case of asthma/COPD (OR=0.31 and if FEVG was >50% (OR=0.62).LVEF < 40% N=661LVEF 40-50% N=282LVEF > 50% N=194Total N=1137At hospital discharge/at entry in the surveyBB78%/83%78%/85%62%/70%76%/82%Recommended BB†75%/77%72%/74%54%/62%71%/74%Reaching the target dose8%/16%7%/16%7%/13%7%/15%Changes since dischargeBB added*28%34%25%28%BB stopped**1%1%2%1%BB dose increased*27%27%17%25%BB dose decreased4%1%3%3%†metoprolol, nebivolol, bisoprolol, carvedilol ;*percentage calculated in patients without BB at hospital discharge (N=278);**percentage calculated in patients with BB at hospital discharge (N=859).ConclusionRate of betablockers prescription is high at hospital discharge. Outhospital cardiologists not only pursue but also amplify the care strategies defined during hospitalisation increasing the proportion of patients receiving BB and the percentage reaching the target dose

The pulmonary autograft after the Ross operation : results of 25 year follow-up in a pediatric cohort

Progressive autograft dilation and need for later reoperation remain major concerns of the Ross procedure. The study investigates the clinical outcome after the Ross operation, including a longitudinal analysis of autograft dimensions over 25 years. From November 1991 to April 2019, 137 patients underwent a Ross procedure at the University Hospitals of UCL (Université catholique de Louvain)-Brussels and Ghent. Inclusion criteria were less than or equal to 18 years of age and pulmonary autograft implantation by root replacement. Outcome focused on survival, reoperation rate, and autograft size evolution through linear mixed-model analysis. A Ross or Ross-Konno operation was performed in 110 (80%) and 27 (20%) patients at a median age of 10.4 (interquartile range [IQR], 4.7-14.3) years and 0.5 (IQR, 0.04-5.2) years, respectively. Overall 10-year and 20-year survival was 87% ± 3% and 85% ± 3%, respectively, but was 93% ± 3% for isolated Ross patients. Right ventricular outflow tract-conduit exchange was required in 20.3%, whereas autograft-related reoperation was performed in 14 (10.7%) patients at a median interval of 14 (IQR, 9-16) years, for aortic regurgitation (n = 2) and autograft dilation (n = 12). Autograft z-values increased significantly at the sinus and sinotubular junction (STJ) compared with the annulus (annulus = 0.05 ± 0.38/y, sinus = 0.14 ± 0.25/y, STJ = 0.17 ± 0.34/y; P = .015). The z-value slope for autograft dimensions was significantly steeper for Ross-Konno vs Ross patients (annulus: P = .029; sinus: P < .001; STJ: P = .012), and for children having aortic arch repair (annulus: P = .113, sinus: P = .038; STJ: P = .029). The Ross operation offers children requiring aortic valve replacement an excellent survival perspective, with an acceptable risk of autograft reoperation within the first 25 years. Contrary to the autograft annulus, dilation of the sinus and STJ size is of concern. Closer surveillance of autograft dimensions might be required in patients who underwent a Ross-Konno procedure or aortic arch reconstruction

The Ross procedure in young adults: over 20 years of experience in our Institution†

OBJECTIVES: The aim of this study was to evaluate the long-term outcomes following the Ross procedure in young adults in our institution. METHODS: All adult patients who received a Ross operation between 1991 and 2014 were included in the study. Survival analysis and regression analysis were performed. Survival of the Ross cohort was compared with the age-, gender- and calendar year-matched general population. RESULTS: Three hundred-and-six patients (mean age: 41.7 ± 9.7, male: 74.8%, bicuspid aortic valve: 58.5%, valve stenosis: 68%) were included in the analysis. There were 7 perioperative deaths (2.3%). Nine patients were lost to follow-up from hospital and completeness of the follow-up was 94%. The median follow-up of the remaining 290 patients was 10.6 years. There were 21 late deaths of which only 3 were valve-related. The overall survival at 15 years since surgery is 88 ± 3% that is comparable with the matched population. Freedom from valve-related deaths was 96.8 ± 2% at 16 years. Freedom from autograft and pulmonary homograft reoperation was 74.5 ± 4.3% at 16 years. Preoperative aortic regurgitation was the only significant predictor of autograft failure over time. Freedom from the combined end point of bleeding/thromboembolism/endocarditis/reoperation was 69.2 ± 4% at 16 years. Perioperative mortality following reoperation was 2.6% and the autograft could be spared in 72% of reinterventions. CONCLUSIONS: The Ross operation in young adults is associated with an excellent survival in the long term that is comparable with the general population. Although there is a risk of reoperation, incidence of other valve-related events is very low. The use of pulmonary autograft should be considered in any young adult patient requiring aortic valve replacement

The role of annular dimension and annuloplasty in tricuspid aortic valve repair†

OBJECTIVES: Valve sparing reimplantation can improve the durability of bicuspid aortic valve repair compared with subcommissural annuloplasty, especially in patients with a large basal ring. This study analyses the effect of basal ring size and annuloplasty on valve repair in the setting of a tricuspid aortic valve. METHODS: From 1995 to 2013, 382 patients underwent elective tricuspid aortic valve repair. We included only those undergoing subcommissural annuloplasty, valve sparing reimplantation or no annuloplasty and in whom intraoperative transoesophageal echocardiography images were available for retrospective pre- and post-repair basal ring measurements (n = 323, subcommissural annuloplasty: 146, valve sparing reimplantation: 154, no annuloplasty: 23). In a subgroup of patients with available echocardiographic images, basal ring was retrospectively measured at the latest follow-up or prior to reoperation. subcommissural annuloplasty and valve sparing reimplantation were compared after matching for degree of aortic regurgitation and root size. RESULTS: All three groups differed significantly for most of preoperative characteristics. Hospital mortality was 0.9%. The median follow-up was 4.7 years. At 8 years, overall survival was 80 ± 5%. Freedom from reoperation and freedom from aortic regurgitation >1+ were 92 ± 5% and 71 ± 8%, respectively. In multivariate analysis, predictors of aortic regurgitation >1+ were left ventricular end-diastolic diameter (P = 0.003), cusp repair (P = 0.006), body surface area (P = 0.01) and subcommissural annuloplasty (P = 0.05). In subcommissural annuloplasty, freedom from aortic regurgitation >1+ was lower for patients with basal ring ≥28 mm compared with patients with basal ring 1+ was independent of basal ring size (P = 0.38). In matched comparison between subcommissural annuloplasty and valve sparing reimplantation, freedom from aortic regurgitation >1+ was not significantly different (P = 0.06), but in patients with basal ring ≥28 mm, valve sparing reimplantation was superior to subcommissural annuloplasty (P = 0.04). Despite similar intraoperative reduction in basal ring size in subcommissural annuloplasty and valve sparing reimplantation, patients with subcommissural annuloplasty exhibited greater increase in basal ring size during the follow-up compared with the valve sparing reimplantation group (P < 0.001). CONCLUSIONS: As with a bicuspid aortic valve, a large basal ring predicts recurrence of aortic regurgitation in patients with tricuspid aortic valve undergoing repair with the subcommissural annuloplasty technique. This recurrence is caused by basal ring dilatation over time after subcommissural annuloplasty. With the valve sparing reimplantation technique, large basal ring did not predict aortic regurgitation recurrence, as prosthetic-based circumferential annuloplasty displayed better stability over time. Stable circumferential annuloplasty is recommended in tricuspid aortic valve repair whenever the basal ring size is ≥28 mm

Aortic valve repair with patch in non-rheumatic disease: indication, techniques and durability†

OBJECTIVES: To analyse the long-term outcomes of aortic valve (AV) repair with biological patch in patient with non-rheumatic valve disease. METHODS: From 1995 to 2011, 554 patients underwent elective (AV) repair; among them, 57 (mean age 45 ± 17 years) had cusp restoration using patch for non-rheumatic valve disease. Seven (12%) patients had unicuspid valve, 30 (53%) patients had bicuspid valve and 20 (35%) had tricuspid valve. Autologous pericardium was used in 26 patients (7 treated, 19 non-treated), bovine pericardium in 26, autologous tricuspid valve leaflet in 4 and aortic homograft cusp in 1. Patching was used to repair perforation (n = 20, 35%), commissural defect (n = 18, 32%), raphe repair (n = 17, 30%) or for cusp extension (n = 2, 3.5%). Echocardiographic and clinical follow-up was 98% complete and mean follow-up was 72 ± 42.5 months. RESULTS: No hospital mortality. At 8 years, overall survival was 90 ± 5% and freedom from valve-related death was 96 ± 3%. Two patients (3.5%) needed early reoperation for aortic regurgitation (AR); they underwent re-repair and the Ross procedure, respectively. Late reoperation was necessary in 9 patients (16%) for AR (n = 4), stenosis (n = 3) or mixed disease (n = 2). They had the Ross procedure (n = 6) or prosthetic valve replacement (n = 3) with no mortality. At 8 years, freedom from reoperation was 75 ± 9%. Freedom from reoperation was slightly higher in tricuspid compared with non-tricuspid valves (92 ± 7 vs 68 ± 11%, P = 0.18) and slightly higher for bovine (95 ± 5%) compared with autologous pericardium (73 ± 11%, P = 0.38), but differences were statistically not significant. In tricuspid valves, freedom from reoperation was higher in perforation repair compared with other techniques (100 vs 50 ± 35%, P = 0.02). In bicuspid valves, freedom from reoperation was similar between different repair techniques (P = 0.38). Late echocardiography showed AR 0-1 in 30 (53%) patients, AR 2 in 12 (21%) and no AR ≥ 3. Three patients presented a mean transvalvular gradient of 30-40 mmHg. Thromboembolic events occurred in 2 patients (0.6%/patient-year), bleeding events in 1 (0.3% /patient-year) and no endocarditis occurred. CONCLUSIONS: AV repair with biological patch is feasible for various aetiologies. The techniques are safe and medium-term durability is acceptable, even excellent for perforation repair in tricuspid valve morphology. Bovine pericardium is a good alternative to autologous pericardium