Impact de la technique de réparation valvulaire sur la fonction ventriculaire gauche post opératoire dans l'insuffisance mitrale primaire par prolapsus du feuillet postérieur

Thèse présentée sous la forme d'une "thèse article"Introduction : l’insuffisance mitrale (IM) primaire est la valvulopathie la plus fréquente dans les pays occidentaux et est associée à un pronostic défavorable sous traitement médical. Lorsque l’indication chirurgicale est posée, la réparation valvulaire est le traitement de référence et doit être effectuée avant la survenue d’une dysfonction du ventricule gauche (VG), première cause de mortalité post opératoire. L’objectif de ce présent travail est de déterminer l’impact de la technique de réparation valvulaire mitrale sur la fonction ventriculaire gauche postopératoire chez les patients opérés d’une IM primaire sévère par prolapsus du feuillet postérieur.Méthodes et résultats : il s’agissait d’une étude monocentrique rétrospective menée sur 10 ans dans le service de chirurgie cardiaque de l’hôpital de la Timone à Marseille. Trois cents trente-quatre patients atteints d’IM primaire sévère par prolapsus du feuillet postérieur ont été consécutivement inclus : 222 patients (66,5%) ont bénéficié d’une réparation valvulaire par néo-cordage (groupe N) et 112 patients (33,5%) d’une réparation valvulaire par résection (groupe R). On observait en préopératoire 30% de patients asymptomatiques et 44 % présentant une dyspnée de stade 2 NYHA, Une FA était présente chez 19 % des patients. La fraction d’éjection du VG était en moyenne à 65 8 % ; 27.80 % patients présentaient une dysfonction VG et 36.50 % une dilatation systolique ventriculaire gauche en préopératoire. L’atteinte isolée de P2 représentaient 76.40 % des lésions traitées.En analyse multivariée, par appariement par score de propension et analyse de sensibilité, la technique chirurgicale n’influençait pas la dysfonction VG en postopératoire immédiat et au 6ème mois. En postopératoire immédiat on retrouvait 29,8 % de dysfonction VG dans le groupe N contre 34 % dans le groupe R (OR 1.20 [0.64-1.94] ; p 0.68) et au 6ème mois, 15,60 % dans le groupe N contre 15,40 % dans le groupe R (OR 0.94 [0.38-2.15] ; p 0.88).La survie actuarielle à 4 ans était de 97.7 % [95.20-100] (groupe N : 99.30 % [97.80-100] ; groupe R : 96,40 % [91.70-100], p 0.47). Le taux de survie sans ré-opération à 4 ans était de 94.80 % [91.50-98.40] (groupe N : 97.70 % [95.20-100] ; groupe R : 91,40 % [85-98.30] ; p 0.21). Le taux de survie sans récidive d’IM modérée ou sévère à 4 ans était de 90,10 % [84.10-96.60] (groupe N : 93.50 % [87.10-100] ; groupe R : 86.50 % [76.60-97.60] ; p 0.36).Conclusion : la dysfonction ventriculaire gauche constitue la première cause de décès postopératoire et doit être impérativement prévenue par une prise en charge plus précoce. Le choix de la technique de réparation valvulaire ne semble pas avoir d’impact sur la fonction systolique ventriculaire gauche. La résection valvulaire et les néo-cordages présentent des résultats précoces satisfaisants et comparables

Venous Thromboembolism Events Following Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Syndrome Coronavirus 2 Based on CT Scans

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Rapid deployment versus trans‐catheter aortic valve replacement in intermediate‐risk patients: A propensity score analysis

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Prosthesis-patient mismatch is an independent predictor of congestive heart failure after transcatheter aortic valve replacement

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Outcomes in nonagenarians undergoing transcatheter aortic valve implantation: a nationwide analysis

International audienceAims: The aim of this study was to describe the midterm outcomes in nonagenarians undergoing transcatheter aortic value implantation (TAVI).Methods and results: Based on the French administrative hospital discharge database, the study collected information for all consecutive patients with aortic stenosis (AS), and specifically those treated with TAVI between 2010 and 2018. Cox regression was used for the analysis of predictors of events. We compared patents according to their age. Within the studied period, 71,095 patients older than 90 years with AS were identified. After matching on baseline characteristics, TAVI was associated with lower rates of a combined outcome of all-cause death, rehospitalisation for heart failure and stroke (relative risk [RR] 0.58, p<0.001) in comparison with matched nonagenarians with AS treated medically. During follow-up (median 161 days, interquartile range 13-625), the combined outcome occurred more frequently in nonagenarians (RR 1.22, p<0.01) who had a TAVI than in younger patients undergoing this procedure. All-cause death was reported in 17.6% versus 14.5% of nonagenarians, rehospitalisation for heart failure in 21.3% versus 18.2%, and stroke in 3.7% versus 2.9% (p<0.01 for all parameters). We identified the Charlson comorbidity index, heart failure, atrial fibrillation, stroke, vascular disease, cognitive impairment and denutrition as independent predictors of adverse outcomes in nonagenarians undergoing TAVI.Conclusions: Among nonagenarians with AS, patients treated with TAVI had a lower risk of cardiovascular events than matched patients treated medically. The patients undergoing a TAVI at this age were often highly selected; the procedure was associated with acceptable long-term outcomes

Volume Analysis to Predict the Long-Term Evolution of Residual Aortic Dissection after Type A Repair

International audienceBackground: The aim of this study was to evaluate the aortic diameter and volume during the first year after a type A repair to predict the long-term prognosis of a residual aortic dissection (RAD). Methods: All patients treated in our center for an acute type A dissection with a RAD and follow-up > 3 years were included. We defined two groups: group 1 with dissection-related events (defined as an aneurysmal evolution, distal reintervention, or aortic-related death) and group 2 without dissection-related events. The aortic diameters and volume analysis were evaluated on three postoperative CT scans: pre-discharge (T1), 3–6 months (T2) and 1 year (T3). Results: Between 2009 and 2016, 54 patients were included. Following a mean follow-up of 75.4 months (SD 31.5), the rate of dissection-related events was 62.9% (34/54). The total aortic diameters of the descending thoracic aorta were greater in group 1 at T1, T2 and T3, with greater diameters in the FL (p < 0.01). The aortic diameter evolution at 3 months was not predictive of long-term dissection-related events. The total thoracic aortic volume was significantly greater in group 1 at T1 (p < 0.01), T2 (p < 0.01), and T3 (p < 0.01). At 3 months, the increase in the FL volume was significantly greater in group 1 (p < 0.01) and was predictive for long-term dissection-related events. Conclusion: This study shows that an initial CT scan volume analysis coupled with another at 3 months is predictive for the long-term evolution in a RAD. Based on this finding, more aggressive treatment could be given at an earlier stage

Transcatheter Valve-in-Valve Aortic Valve Replacement as an Alternative to Surgical Re-Replacement

International audienceBACKGROUND Valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) and redo surgical aortic valve replacement (SAVR) represent the 2 treatments for aortic bioprosthesis failure. Clinical comparison of both therapies remains limited by the number of patients analyzed. OBJECTIVES The purpose of this study was to analyze the outcomes of VIV TAVR versus redo SAVR at a nationwide level in France.METHODS Based on the French administrative hospital-discharge database, the study collected information for patients treated for aortic bioprosthesis failure with isolated VIV TAVR or redo SAVR between 2010 and 2019. Propensity score matching was used for the analysis of outcomes.RESULTS A total of 4,327 patients were found in the database. After matching on baseline characteristics, 717 patients were analyzed in each arm. At 30 days, VIV TAVR was associated with lower rates of the composite of all-cause mortality, all-cause stroke, myocardial infarction, and major or life-threatening bleeding (odds ratio: 0.62; 95% confidence interval: 0.44 to 0.88; p = 0.03). During follow-up (median 516 days), the combined endpoint of cardiovascular death, all-cause stroke, myocardial infarction, or rehospitalization for heart failure was not different between the 2 groups (odds ratio: 1.18; 95% confidence interval: 0.99 to 1.41; p = 0.26). Rehospitalization for heart failure and pacemaker implantation were more frequently reported in the VIV TAVR group. A time-dependent interaction between all-cause and cardiovascular mortality following VIV TAVR was reported (p-interaction <0.05).CONCLUSIONS VIV TAVR was observed to be associated with better short-term outcomes than redo SAVR. Major cardiovascular outcomes were not different between the 2 treatments during long-term follow-up

Prognostic value of forward flow indices in primary mitral regurgitation due to mitral valve prolapse

Degenerative mitral regurgitation (DMR) due to mitral valve prolapse (MVP) is a common valve disease associated with significant morbidity and mortality. Timing for surgery is debated for asymptomatic patients without Class I indication, prompting the search for novel parameters of early left ventricular (LV) systolic dysfunction. Aims To evaluate the prognostic impact of preoperative forward flow indices on the occurrence of post-operative LV systolic dysfunction. Methods We retrospectively included all consecutive patients with severe DMR due to MVP who underwent mitral valve repair between 2014 and 2019. LVOT TVI , forward stroke volume index, and forward LVEF were assessed as potential risk factors for LVEF &lt;50% at 6 months post-operatively. Results A total of 198 patients were included: 154 patients (78%) were asymptomatic, and 46 patients (23%) had hypertension. The mean preoperative LVEF was 69 ± 9%. 35 patients (18%) had LVEF ≤ 60%, and 61 patients (31%) had LVESD ≥40 mm. The mean post-operative LVEF was 59 ± 9%, and 21 patients (11%) had post-operative LVEF&lt;50%. Based on multivariable analysis, LVOT TVI was the strongest independent predictor of post-operative LV dysfunction after adjustment for age, sex, symptoms, LVEF, LV end systolic diameter, atrial fibrillation and left atrial volume index (0.75 [0.62–0.91], p &lt; 0.01). The best sensitivity (81%) and specificity (63%) was obtained with LVOTTVI ≤15 cm based on ROC curve analysis. Conclusion LVOT TVI represents an independent marker of myocardial performance impairment in the presence of severe DMR. LVOT TVI could be an earlier marker than traditional echo parameters and aids in the optimization of the timing of surgery

Myocardial Revascularization Strategies in ST Elevation Myocardial Infarction Without Urgent Revascularization: Insight From a Nationwide Study

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Editorial, see p 269

International audienceBackground: Two competing transcatheter aortic valve replacement (TAVR) technologies are currently available. Head-to-head comparisons of the relative performances of these 2 devices have been published. However, long-term clinical outcome evaluation remains limited by the number of patients analyzed, in particular, for recent-generation devices.Methods:Based on the French administrative hospital-discharge database, the study collected information for all consecutive patients treated with a TAVR device commercialized in France between 2014 and 2018. Propensity score matching was used for the analysis of outcomes during follow-up. The objective of this study was to analyze the outcomes of TAVR according to Sapien 3 balloon-expandable (BE) versus Evolut R self-expanding TAVR technology at a nationwide level in France.Results:A total of 31 113 patients treated with either Sapien 3 BE or Evolut R self-expanding TAVR were found in the database. After matching on baseline characteristics, 20 918 patients were analyzed (10 459 in each group with BE or self-expanding valves). During follow-up (mean [SD], 358 [384]; median [interquartile range], 232 [10-599] days), BE TAVR was associated with a lower yearly incidence of all-cause death (relative risk, 0.88; corrected P=0.005), cardiovascular death (relative risk, 0.82; corrected P=0.002), and rehospitalization for heart failure (relative risk, 0.84; corrected P<0.0001). BE TAVR was also associated with lower rates of pacemaker implantation after the procedure (relative risk, 0.72; corrected P<0.0001).Conclusions: On the basis of the largest cohort available, we observed that Sapien 3 BE valves were associated with lower rates of all-cause death, cardiovascular death, rehospitalization for heart failure, and pacemaker implantation after a TAVR procedure