Alain Cribier

Tissue Doppler Imaging Differentiates Transmural From Nontransmural Acute Myocardial Infarction After Reperfusion Therapy

Background —The evaluation of transmural extent of necrosis after acute myocardial infarction remains a major problem in clinical practice. We sought to determine whether color M-mode tissue Doppler imaging (TDI) could differentiate transmural from nontransmural myocardial infarction. Methods and Results —Twenty-one anesthetized open-chest dogs underwent 90 or 120 minutes of left anterior descending coronary artery occlusion followed by 180 minutes of reperfusion. The transmural extension of infarct was measured by triphenyltetrazolium chloride (TTC) staining. Segment shortening in the endocardium and epicardium of the anterior and posterior walls was assessed by sonomicrometry. Regional myocardial blood flow was measured by radioactive microspheres. TDI was obtained from an epicardial short-axis view. We calculated systolic and diastolic velocities within the endocardium and epicardium of myocardial walls and the subsequent myocardial velocity gradient (MVG). TTC staining could identify 2 groups according to the transmural extent of necrosis: 15 dogs had a nontransmural (NT) necrosis (42±3% of wall thickness), and 6 dogs developed a transmural (T) infarct (81±4% of wall thickness). In both groups, ischemia resulted in a significant and similar reduction in endocardial and epicardial velocities, with a resulting low systolic MVG in the anterior wall (0.10±0.07 in NT and 0.10±0.08 s−1 in T). At 60 minutes of reperfusion, systolic MVG failed to change significantly in the transmural group (−0.20±0.09 s−1). In contrast, it increased significantly after reflow in the NT group compared with ischemic values (−0.99±0.20 versus 0.10±0.07 s−1, P <0.05). Conclusions —TDI can differentiate transmural from nontransmural myocardial infarction early after reperfusion.

Transfemoral Aortic Valve Replacement With the Edwards SAPIEN and Edwards SAPIEN XT Prosthesis Using Exclusively Local Anesthesia and Fluoroscopic Guidance: Feasibility and 30-Day Outcomes

OBJECTIVESnThe authors report the feasibility and 30-day outcomes of transfemoral aortic valve replacement (TAVR), using the Edwards SAPIEN (Edwards Lifesciences, Irvine, California) and Edwards SAPIEN XT (Edwards Lifesciences) prosthesis, implanted using exclusively local anesthesia and fluoroscopic guidance.nnnBACKGROUNDnTransfemoral TAVR is often managed with general anesthesia. However, a simplified percutaneous approach using local anesthesia has become more popular because it offers multiple advantages in an elderly and fragile population.nnnMETHODSnBetween May 2006 and January 2011, the authors prospectively evaluated 151 consecutive patients (logistic EuroSCORE: 22.8 ± 11.8%) who underwent TAVR (SAPIEN: n = 78, SAPIEN XT: n = 73) using only local anesthesia and fluoroscopic guidance. The primary endpoint was a combination of all-cause mortality, major stroke, life-threatening bleeding, stage 3 acute kidney injury (AKI), periprocedural myocardial infarction (MI), major vascular complication, and repeat procedure for valve-related dysfunction at 30 days.nnnRESULTSnTransarterial femoral approach was surgical in all SAPIEN procedures and percutaneous in 97.3% of SAPIEN XT, using the ProStar vascular closure device, and was well tolerated in all cases. Conversion to general anesthesia was required in 3.3% (SAPIEN cases) and was related to complications. Vasopressors were required in 5.5%. Procedural success was 95.4%. The combined-safety endpoint was reached in 15.9%, including overall mortality (6.6%), major stroke (2.0%), life-threatening bleeding (7.9%), stage 3 AKI (0.7%), periprocedural MI (1.3%), major vascular complication (7.9%), and repeat procedure for valve-related dysfunction (2.0%) at 30 days. A permanent pacemaker was required in 5.3%.nnnCONCLUSIONSnThis single-center, prospective registry demonstrated the feasibility and safety of a simplified transfemoral TAVR performed using only local anesthesia and fluoroscopic guidance in high surgical risk patients with severe aortic stenosis.

Incidence, predictors and impact of bleeding after transcatheter aortic valve implantation using the balloon-expandable Edwards prosthesis

Objectives To evaluate the incidence, predictors and impact of bleeding after transcatheter aortic valve implantation (TAVI). Design Single-centre prospective observational study. Setting Charles Nicolle University Hospital, Rouen, France. Interventions We included 250 consecutive patients who underwent TAVI between May 2006 and October 2011. All procedures were performed using Edwards SAPIEN and SAPIEN XT valves via transfemoral (TF) and transapical (TA) routes. Surgical cutdown was used for TF access when implanting the SAPIEN valve, while percutaneous access was used for SAPIEN XT implantation. Life-threatening bleeding (LTB), major and minor bleeding and other complications were defined using Valve Academic Research Consortium criteria. Results TAVI was performed via TF access in 190 cases (76%) and the SAPIEN XT valve was used in 123 cases (49.2%). Bleeding after TAVI was noted in 68 patients (27.2%): LTB in 33 (13.2%), major bleeding in 23 (9.2%) and minor bleeding in 12 (4.8%). By multivariate analysis, only TA access was an independent predictor of LTB (OR 3.7, 95% CI 1.73 to 7.9, p=0.001). Patients presenting with LTB after TAVI had a higher 30-day mortality (33.3% vs 3.7%, p<0.001) and 1-year mortality (54% vs 18%, p<0.001). LTB was an independent predictive factor of 1-year mortality (HR 2.54, 95% CI 1.3 to 4.9, p=0.002). Conclusions Bleeding is a frequent complication of TAVI, occurring in 27% of cases. LTB is associated with higher 30-day and 1-year mortality.

Performance Analysis of EuroSCORE II Compared to the Original Logistic EuroSCORE and STS Scores for Predicting 30-Day Mortality After Transcatheter Aortic Valve Replacement

The original European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been recently updated as EuroSCORE II to optimize its efficacy in cardiac surgery, but its performance has been poorly evaluated for predicting 30-day mortality in patients who undergo transcatheter aortic valve replacement (TAVR). Consecutive patients (n = 250) treated with TAVR were included in this analysis. Transapical access was used in 60 patients, while 190 procedures were performed using a transfemoral approach. Calibration (risk-adjusted mortality ratio) and discrimination (C-statistic and U-statistic) were calculated for the logistic EuroSCORE, EuroSCORE II, and Society of Thoracic Surgeons (STS) scores for predicting 30-day mortality. Observed mortality was 7.6% in the overall population (6.3% and 11.7% for the transfemoral and transapical cohorts, respectively). Predicted mortality was 22.6 ± 12.8% by logistic EuroSCORE, 7.7 ± 5.8% by EuroSCORE II, and 7.3 ± 4.1% by STS score. The risk-adjusted mortality ratio was 0.34 (95% confidence interval [CI] 0.10 to 0.58) for logistic EuroSCORE, 0.99 (95% CI 0.29 to 1.69) for EuroSCORE II, and 1.05 (95% CI 0.30 to 1.79) for STS score. Moderate discrimination was observed with EuroSCORE II (C-index 0.66, 95% CI 0.52 to 0.79, p = 0.02) compared to the logistic EuroSCORE (C-index 0.63, 95% CI 0.51 to 0.76, p = 0.06) and STS (C-index 0.58, 95% CI 0.43 to 0.73, p = 0.23) score, without a significant difference among the 3 risk scores. Discrimination was slightly better in the transfemoral cohort compared to the transapical cohort with the 3 risk scores. In conclusion, EuroSCORE II and the STS score are better calibrated than the logistic EuroSCORE but have moderate discrimination for predicting 30-day mortality after TAVR.

Balloon aortic valvuloplasty in the era of transcatheter aortic valve replacement: acute and long-term outcomes.

BACKGROUNDnThe use of balloon aortic valvuloplasty (BAV) has resurged since the development of transcatheter aortic valve replacement (TAVR). The aim of our study was to determine the procedural and long-term outcomes of patients treated by BAV in the early TAVR era.nnnMETHODSnFrom 2005 to 2008, 323 consecutive patients presenting with severe aortic stenosis were treated by BAV in our institution.nnnRESULTSnMean age and logistic EuroSCORE were 80.5 ± 9.9 years and 28.7% ± 12.5%, respectively. The effective orifice area increased from 0.68 ± 0.25 to 1.12 ± 0.39 cm(2) (P < .001) after BAV. Inhospital major complications occurred in 22 patients (6.8%), with a mortality rate of 2.5%. Eighty-five patients (26.3%) were bridged to surgical aortic valve replacement (SAVR, 9.6%) or TAVR (16.7%). Twenty-eight patients (8.7%) had at least 1 repeat BAV. Two hundred ten patients (65%) received only medical therapy post-BAV. Mean duration of follow-up was 20.7 ± 20.0 months. Kaplan-Meier analysis demonstrated that survival after single BAV was poor. Patients treated by BAV followed by SAVR or TAVR had the highest long-term survival rate (P < .001). Multivariable analysis revealed that logistic EuroSCORE, severe aortic regurgitation and stroke complications post-BAV, and medical therapy post-BAV were independent predictors of mortality.nnnCONCLUSIONSnThe results of our study suggest that BAV is an acceptable bridge to SAVR or TAVR in a very high-risk population not immediately suitable for definitive therapy. Balloon aortic valvuloplasty remains only a brief temporizing procedure with a poor long-term outcome without subsequent definitive therapy.

Comparison of Two Antiplatelet Therapy Strategies in Patients Undergoing Transcatheter Aortic Valve Implantation

Dual antiplatelet therapy is commonly used in patients undergoing transcatheter aortic valve implantation (TAVI), but the optimal antiplatelet regimen is uncertain and remains to be determined. The objective of this study was to compare 2 strategies of antiplatelet therapy in patients undergoing TAVI. A strategy using monoantiplatelet therapy (group A, n = 164) was prospectively compared with a strategy using dual antiplatelet therapy (group B, n = 128) in 292 consecutive patients undergoing TAVI. The primary end point was a combination of mortality, major stroke, life-threatening bleeding (LTB), myocardial infarction, and major vascular complications at 30 days. All adverse events were adjudicated according to the Valve Academic Research Consortium. The primary end point occurred in 22 patients (13.4%) in the group A and in 30 patients (23.4%) in the group B (hazard ratio 0.51, 95% confidence interval 0.28 to 0.94, p = 0.026). LTB (3.7% vs 12.5%, p = 0.005) and major bleedings (2.4% vs 13.3%, p <0.0001) occurred less frequently in the group A, whereas the incidence of stroke (1.2% vs 4.7%, p = 0.14) and myocardial infarction (1.2% vs 0.8%, p = 1.0) was not significantly different between the 2 groups. The benefit of a strategy using mono versus dual antiplatelet therapy persisted after multivariate adjustment and propensity score analysis (hazard ratio 0.53, 95% confidence interval 0.28 to 0.95, p = 0.033). In conclusion, a strategy using mono versus dual antiplatelet therapy in patients undergoing TAVI reduces LTB and major bleedings without increasing the risk of stroke and myocardial infarction. The results of our study question the justification of dual antiplatelet therapy and require confirmation in a randomized trial.

Immediate and long-term echocardiographic findings after transcatheter aortic valve implantation for the treatment of aortic stenosis: the Cribier-Edwards/Edwards-Sapien valve experience.

BACKGROUNDnThe role of transcatheter aortic valve implantation in the treatment of calcific aortic stenosis is evolving. Immediate and long-term echocardiographic findings are poorly reported.nnnMETHODSnEighty-eight patients in whom surgical aortic valve replacement was contraindicated were studied before and 1 and 7 days, 1 month, and 1 and 2 years after the transcatheter procedure by echocardiography for hemodynamic. Transaortic pressure gradient, permeability index, and aortic valve area were measured, and aortic regurgitation was estimated from a multiparametric approach. A subset group of 36 patients (23-mm valve, n = 18; 26-mm valve, n = 18) with optimal ultrasound window were investigated for valve geometry at 7 days. We measured the sphericity index (anteroposterior to sagittal diameter ratio) and the angulation of the prosthesis with the ascending aorta.nnnRESULTSnBy analysis of variance, transaortic pressure gradient significantly decreased and aortic valve area increased after the procedure (P < .0001 and P < .0001 respectively). Aortic regurgitation severity tended to decline at follow-up (P = .20) and was unaffected by valve size (P = .35). Leaks were paraprosthetic in 77% of cases, intraprosthetic in 6% of cases, and both in 17% of cases. Overall, the sphericity index was 1.03 +/- 0.07 and the angulation was 2.9 +/- 1.1 degrees.nnnCONCLUSIONnEchocardiography aids in the demonstration of appropriate prosthesis function and positioning after transcatheter aortic valve implantation.

Technique of Transcatheter Aortic Valve Implantation with the Edwards-Sapien® Heart Valve Using the Transfemoral Approach

Transcatheter aortic valve implantation (TAVI) using a balloon-expandable valve has been developed by the authors’ group 7 years ago to offer a therapeutic solution to nonoperable or surgical high-risk patients with degenerative aortic stenosis. The technique and the devices used have rapidly evolved thereafter and TAVI has become a clinical reality with more than 3,500 patients implanted worldwide with this device. The currently used Edwards-Sapien® Transcatheter Heart Valve (THV) consists of a balloon-expandable stent with an integrated bovine pericardial valve. It can be implanted within the diseased native aortic valve using either the retrograde transfemoral or antegrade transapical routes.This article is aimed at describing the updated transfemoral technique. Appropriate patient selection is crucial for a successful procedure including close evaluation of the arterial characteristics. After predilatation of the native valve with a balloon catheter, the THV with its delivery system is introduced within the femoral artery, advanced to the native aortic valve under X-ray control, positioned across the aortic annulus, and delivered by balloon inflation under rapid heart pacing. The acute procedural success is 96% and the technique leads to an immediate and lasting improvement of hemodynamics and clinical status. Complications are rare and the mortality rate is 6.3% at 1 month in this cohort of very sick patients. Procedural complications are headed by vascular injury related to the large size of the arterial introducers. An upcoming lower- profile Edwards THV should improve this issue and increase the indication for this less invasive approach in the near future. At the present time, the indications should be restricted to nonoperable or surgical highrisk patients and the procedure performed by experienced and formally trained physicians working in an optimal multidisciplinary environment.ZusammenfassungDie Transkatheter-Aortenklappenimplantation (TAVI) unter Verwendung einer ballonexpandierbaren Klappe wurde vor 7 Jahren von den Autoren entwickelt, um inoperablen oder chirurgischen Hochrisikopatienten mit degenerativer Aortenstenose eine therapeutische Lösung anzubieten. Die Technik und die verwendeten Devices haben sich danach schnell weiterentwickelt, und die TAVI ist mit weltweit mehr als 3 500 behandelten Patienten klinische Realität geworden. Die derzeit verwendeteEdwards-Sapien®-Transkatheter-Herzklappe (THV) besteht aus einem ballonexpandierbaren Stent mit einer integrierten biologischen (Rinderperikard) Herzklappenprothese. Sie kann über den retrograden transfemoralen oder den antegraden transapikalen Weg in die kranke native Aortenklappe eingepflanzt werden. Dieser Artikel beschreibt die modernisierte transfemorale Technik. Für eine erfolgreiche Durchführung ist eine entsprechende Patientenauswahl einschließlich genauer Evaluation der Arterieneigenschaften entscheidend. Nach Prädilatation der nativen Klappe mit einem Ballonkatheter wird die THV mit ihrem Zuführungssystem in die Schenkelarterie eingeführt, unter Röntgenkontrolle zur nativen Aortenklappe vorgeschoben, über dem Aortenbogen in Position gebracht und durch Aufdehnung des Ballons unter schneller Stimulation eingesetzt. Die akute technische Erfolgsrate liegt bei 96%, und die Technik führt zu einer sofortigen und dauerhaften Verbesserung der Hämodynamik und des klinischen Status. Komplikationen sind selten, und die Sterbeziffer liegt in dieser Kohorte schwerkranker Patienten nach 1 Monat bei 6,3%. An der Spitze der Verfahrenskomplikationen stehen Gefäßverletzungen im Zusammenhang mit der Größe der arteriellen Schleuse. Eine demnächst verfügbare Niedrigprofil- Edwards-THV sollte diesbezüglich zu einer Besserung führen und die Indikationen für diesen weniger invasiven Zugang in naher Zukunft erweitern. Gegenwärtig sollten die Indikationen auf inoperable oder chirurgische Hochrisikopatienten beschränkt und das Verfahren nur von erfahrenen und speziell geschulten Ärzten in einem optimalen multidisziplinären Umfeld durchgeführt werden.

Preoperative tissue Doppler imaging differentiates beneficial from detrimental left ventricular hypertrophy in patients with surgical aortic stenosis. A postoperative morbidity study

Background: In a pressure overloaded left ventricle, regional systolic function has often deteriorated despite normal ejection fraction. Objective: To correlate regional systolic function obtained by tissue Doppler imaging (TDI) with improvement in functional status after aortic valve replacement in patients with aortic stenosis (AS). Methods and results: 24 hours before aortic valve replacement, 32 patients with severe AS underwent conventional and TDI echocardiography for systolic peak velocity, peak strain and peak strain rate measurement in the short-axis posterior wall. At follow-up, a composite end point of cardiovascular death, worsening of heart failure and limited exercise capacity was recorded. Before surgery, mean (SD) aortic valve area and pressure gradient were 0.69 (0.22) cm2 and 50 (14) mm Hg, respectively. Ejection fraction was 61 (10)% and septal thickness was 15 (3) mm. Fourteen events were recorded but no cardiac death. By using the multivariate regression analysis, systolic peak strain rate (pu200a=u200a0.003) was the strongest predictor of limited recovery after aortic valve replacement. The peak strain rate cut-off point was 2/s by receiver operating characteristic analysis. Conclusion: Irrespective of ejection fraction and thickness, strain rate is a determinant which predicts recovery after aortic valve replacement in patients with severe AS.

Patients With Severe Aortic Stenosis and Reduced Ejection Fraction: Earlier Recovery of Left Ventricular Systolic Function After Transcatheter Aortic Valve Implantation Compared With Surgical Valve Replacement

Only 50% of patients with aortic stenosis (AS) and low ejection fraction (EF) improve their contractility after surgical aortic valve replacement (AVR). Long‐term prognosis of these patients is strongly correlated to EF recovery after the surgery. The aim of this study was to compare the postoperative left ventricular function recovery in patients with severe AS and reduced EF after AVR and transcatheter aortic valve implantation (TAVI).