Anne-Sophie Polge

Echocardiography predictors and prognostic value of pulmonary artery systolic pressure in chronic organic mitral regurgitation

Objective To evaluate the predictors of pulmonary artery systolic pressure (PASP) in organic mitral regurgitation (MR) and its prognostic value after surgery. Design Prospective observational study, conducted from 1998 to 2006. Setting Echocardiography and cardiac surgery departments, University Hospital. Patients Echocardiography was carried out in 256 patients (63±12 years, 170 male) with organic MR (degenerative aetiology: 91%) referred for surgery. Main outcome measures Echocardiography predictors of PASP. Postoperative end points were overall mortality and cardiovascular mortality. Results Baseline PASP was 45±14 mmHg, ranging from 25 to 105 mmHg. PASP was ≥50 mmHg in 82 patients (32%). Left atrial volume (p=0.003), mitral deceleration time (p<0.0001) and mitral medial E/E′ (p<0.0001) were independent predictors of PASP, whereas left ventricular size and systolic function were not predictors. Mitral valve repair was performed in 194 patients (76%) and mitral valve replacement in 62 (24%). In a Cox model mitral valve repair (HR=0.41 (95% CI 0.20 to 0.85), p=0.016) and PASP (HR=1.43 (95% CI 1.09 to 1.88) per 10 mmHg increment, p=0.011) were independent predictors of overall mortality, even after adjustment for known predictors. PASP (HR=1.49 (95% CI 1.03 to 2.16) per 10 mmHg increment, p=0.033) was also an independent predictor of cardiac mortality. Eight-year survival after surgery was 58.6% and 86.6% in patients with baseline PASP ≥50 mmHg or <50 mmHg, respectively (p<0.0001). Conclusions In organic MR, mitral deceleration time, mitral E/E′ and left atrial volume correlate with PASP. Pulmonary artery systolic pressure ≥50 mmHg is an independent predictor of overall and cardiovascular mortality after surgery in organic MR.

Functional Impairment of Von Willebrand Factor in Hypertrophic Cardiomyopathy: Relation to Rest and Exercise Obstruction

Background— Hypertrophic obstructive cardiomyopathy submits blood to conditions of high shear stress. High shear stress impairs von Willebrand factor (VWF) and promotes abnormal bleeding in aortic stenosis. We sought to evaluate VWF impairment and its relationships to baseline or exercise obstruction in hypertrophic cardiomyopathy (HCM). Methods and Results— Outflow obstruction was evaluated by rest and exercise echocardiography in 62 patients with HCM (age 44±16 years, 40 males). HCM was considered obstructive in 28 patients with rest or exercise peak gradient ≥30 mm Hg. Blood was sampled to assess VWF. History of bleeding was recorded. Baseline median (25th to 75th percentile) peak gradient was 11 (5–62) mm Hg. Shear-induced platelet adhesion was impaired in patients with obstructive HCM. The ratio of VWF–collagen-binding activity to antigen and the percentage of high-molecular-weight multimers of VWF were lower in patients with obstructive HCM than in those with nonobstructive HCM (0.49 [0.43 to 0.59] versus 0.82 [0.73 to 1.03] and 5.0% [3.9% to 7.2%] versus 11.7% [10.8% to 12.5%], respectively; both P<0.0001). Platelet adhesion time, VWF–collagen-binding activity–to-antigen ratio, and the percentage of high-molecular-weight multimers correlated closely and independently with peak gradient (r=0.81, r=−0.68, and r=−0.89, respectively; all P<0.0001). According to receiver operating characteristic curves, a peak gradient threshold of 15 mm Hg at rest and 35 mm Hg during exercise was sufficient to impair VWF. Conversely, VWF function tended to improve with a decrease in peak gradient. Obstructive HCM patients had a trend toward abnormal spontaneous bleeding. Conclusions— In obstructive HCM, VWF impairment is frequent and is closely and independently related to the magnitude of outflow obstruction. A resting peak gradient of 15 mm Hg is sufficient to impair VWF. VWF abnormalities might favor abnormal bleeding in this setting.

Transcatheter closure of atrial septal defect with the Figulla® ASD Occluder: A comparative study with the Amplatzer® Septal Occluder

BACKGROUND Single-centre experience in transcatheter closure of atrial septal defect (ASD) using the Figulla(®) ASD Occluder (FSO; Occlutech GmbH, Jena, Germany) and the Amplatzer(®) Septal Occluder (ASO; Saint-Jude Medical, Zaventem, Belgium) has been reported. AIM To perform a retrospective comparison of the two occluders. METHODS From September 2009 to December 2012, 131 consecutive patients underwent percutaneous ASD occlusion: One hundred with the ASO device; 31 with the FSO device. RESULTS There were no significant differences between the two groups regarding patient characteristics, stretched diameter, age and device size. In the ASO group, implantation succeeded in all but two patients because of deficient rim. Another patient had device embolization in the aorta retrieved percutaneously. During follow-up, 86 patients had no residual shunt and nine patients had a residual shunt (small in seven; moderate in two). Two other patients had persistent interatrial small shunt caused by an adjacent ASD close to the device. In the FSO group, implantation succeeded in all but two patients: one because of deficient posterior rim; and one because of complete atrioventricular block that resolved after device extraction. During follow-up, no shunt was observed in all but one patient. At late follow-up (up to 36months), full occlusion was observed in 88 (88.0%) patients in the ASO group and 28 (90.3%) patients in the FSO group (with no significant difference between groups). CONCLUSION Transcatheter closure of ASD with the FSO is feasible and safe. FSO results compare favorably with ASO results. However, additional long-term studies that include more patients are mandatory.

Ross procedure is a safe treatment option for aortic valve endocarditis: Long-term follow-up of 42 patients

BACKGROUND Aortic root replacement with a pulmonary autograft (Ross procedure) can be performed as a treatment of aortic valve endocarditis, avoiding prosthetic valve implantation in septic context. We sought to assess long-term outcomes of the Ross procedure in this indication. METHODS From April 1992 to March 2009, the intervention was performed in 42 patients (mean age 34 ± 8 years) suffering from an active or ancient aortic valve endocarditis. 36% of the patients had extensive perivalvular involvement, and surgery was urgent in 18 patients (43%). We performed a prospective clinical and echocardiographic follow-up of this population. RESULTS Median follow-up was 10 years (4-21 years). Overall survival at 10 and 15 years was respectively 87 ± 5% and 81 ± 8%. Perioperative mortality was 4.7% (2 patients) and no late cardiac death was reported. Eight patients (19%) underwent repeat surgery for autograft and/or homograft dysfunction at a median time of 8.4 years (3 months-18 years). Rate of recurrent endocarditis was low (7%-3 patients), including 1 in a context of persistent intravenous drug abuse. Clinical follow-up showed good functional status for all patients with NYHA ≤ II, and less than 25% of patients requiring cardiovascular medication. Late echocardiographic follow-up demonstrated well-functioning autograft and homograft, with only one severe aortic regurgitation, and one significant increase in pulmonary mean gradient. CONCLUSION The Ross procedure in aortic valve endocarditis is an interesting alternative to prosthetic valvular replacement in a selected population, with a high rate of survival free from any cardiovascular event or medication requirement.

Prospective assessment of multiple cardiac papillary fibroelastomas: An echocardiographic and surgical study

Multiple cardiac papillary fibroelastomas (PFEs) are thought to account for less than 10% of patients with PFE. We aimed at evaluating the frequency and location of multiple PFEs and the reliability of transthoracic (TTE) and transoesophageal (TEE) echocardiography in diagnosing multiple PFEs. Twenty-six consecutive patients (52±14 years, 65% males) with pathologically confirmed PFE had 21 PFEs diagnosed by TTE, 33 by TEE, and 62 at surgery. Eight patients (31%) had multiple PFEs found either by TEE or at surgery. Aortic valve was involved in 75% of patients with multiple PFEs and left ventricle in 38% of patients. The sensitivity of TTE in diagnosing any PFEs was 51.3% and 76.9% for TEE. Our study emphasizes the high frequency of multiple PFEs, the need of TEE for all presumed PFE and the need for careful assessment of left-sided endocardial surfaces, especially of the aortic valve, during PFE excision.

Echographie tridimensionnelle: applications cardio-vasculaires.

Resume Dans le domaine cardio-vasculaire, l’echographie tridimensionnelle est en train de s’imposer comme une nouvelle modalite de l’echographie essentiellement depuis l’avenement de l’imagerie en temps reel. L’imagerie de rendu volumique permet une meilleure identification et localisation des structures anatomiques et ameliore notre comprehension de nombreuses pathologies. Les trois principales applications emergentes sont representees par l’etude des valvulopathies mitrales, des cardiopathies congenitales et par les mesures de volume, masse et fraction d’ejection du ventricule gauche. L’imagerie vasculaire tridimensionnelle est a la phase toute initiale de son developpement, elle apparait cependant prometteuse sur le plan clinique. L’avenir de l’echographie tridimensionnelle passe par une integration de l’ensemble des modalites anterieures de l’echocardiographie a l’imagerie tridimensionnelle qui doit s’ameliorer en termes de resolution ainsi que par la mise au point de sondes tridimensionnelles en temps reel pour l’exploration par voie trans-oesophagienne et pour l’exploration vasculaire.

0398: Transcatheter closure of traumatic induced VSD

Traumatic induced VSD is a rare but serious disease because of the acute hemodynamic changes. We reported one center experience in the interventional catheterization closure of traumatic induced VSD during the last ten years. We had 3 patients with four VSD. Mean age was 60 (40-71) years. VSD was muscular secondary to external trauma in one patient, and to transapical transcatheter replacement of both of the aortic and mitral valves in the second. Last patient had membranous and muscular VSD post Ross-Konno intervention. All patients had acute congestive heart failure. All procedures were performed under general anesthesia and transesophageal echocardiography control. Arteriovenous loop was always used to introduce the delivery sheath to the left ventricle. VSDs diameter was evaluated by echography and ranged from 9 to 13mm. Device diameter was chosen 1 to 2mm over the echo-graphic measures. Multiple devices were used (Amplatzer® septal occluder, Amplatzer® muscular VSD occluder, Occlutech® Figulla septal occluder). Mean procedures time was 113 (100-145) min, and mean irradiation dose was 160 (103-203) Gycm2. Non significant residual shunt was observed in all patients, but the heart failure was resolved in all. Complications were registered in three procedures: transient hemolytic anemia, severe bradycardia, tricuspid cordage rupture and groin hematoma. Conclusion Traumatic VSD closure is required because of the acute hemo-dynamic changes. Trancatheter closure is effective. Complications are frequents because of the critical clinical status.

Right Ventricular Systolic Function in Organic Mitral RegurgitationCLINICAL PERSPECTIVE

Background— To assess the prevalence, determinants, and prognosis value of right ventricular (RV) ejection fraction (EF) impairment in organic mitral regurgitation. Methods and Results— Two hundred eight patients (62±12 years, 138 males) with chronic organic mitral regurgitation referred to surgery underwent an echocardiography and biventricular radionuclide angiography with regional function assessment. Mean RV EF was 40.4±10.2%, ranging from 10% to 65%. RV EF was severely impaired (⩽35%) in 63 patients (30%), and biventricular impairment (left ventricular EF<60% and RV EF⩽35%) was found in 34 patients (16%). Pathophysiologic correlates of RV EF were left ventricular septal function (&bgr;=0.42, P<0.0001), left ventricular end-diastolic diameter index (&bgr;=−0.22, P=0.002), and pulmonary artery systolic pressure (&bgr;=−0.14, P=0.047). Mitral effective regurgitant orifice size (n=84) influenced RV EF (&bgr;=−0.28, P=0.012). In 68 patients examined after surgery, RV EF increased strongly (27.5±4.3–37.9±7.3, P<0.0001) in patients with depressed RV EF, whereas it did not change in others (P=0.91). RV EF ⩽35% impaired 10-year cardiovascular survival (71.6±8.4% versus 89.8±3.7%, P=0.037). Biventricular impairment dramatically reduced 10-year cardiovascular survival (51.9±15.3% versus 90.3±3.2%, P<0.0001; hazard ratio, 5.2; P<0.0001) even after adjustment for known predictors (hazard ratio, 4.6; P=0.004). Biventricular impairment reduced also 10-year overall survival (34.8±13.0% versus 72.6±4.5%, P=0.003; hazard ratio, 2.5; P=0.005) even after adjustment for known predictors (P=0.048). Conclusions— In patients with organic mitral regurgitation referred to surgery, RV function impairment is frequent (30%) and depends weakly on pulmonary artery systolic pressure but mainly on left ventricular remodeling and septal function. RV function is a predictor of postoperative cardiovascular survival, whereas biventricular impairment is a powerful predictor of both cardiovascular and overall survival.

Right Ventricular Systolic Function in Organic Mitral RegurgitationCLINICAL PERSPECTIVE: Impact of Biventricular Impairment

Background— To assess the prevalence, determinants, and prognosis value of right ventricular (RV) ejection fraction (EF) impairment in organic mitral regurgitation. Methods and Results— Two hundred eight patients (62±12 years, 138 males) with chronic organic mitral regurgitation referred to surgery underwent an echocardiography and biventricular radionuclide angiography with regional function assessment. Mean RV EF was 40.4±10.2%, ranging from 10% to 65%. RV EF was severely impaired (⩽35%) in 63 patients (30%), and biventricular impairment (left ventricular EF<60% and RV EF⩽35%) was found in 34 patients (16%). Pathophysiologic correlates of RV EF were left ventricular septal function (&bgr;=0.42, P<0.0001), left ventricular end-diastolic diameter index (&bgr;=−0.22, P=0.002), and pulmonary artery systolic pressure (&bgr;=−0.14, P=0.047). Mitral effective regurgitant orifice size (n=84) influenced RV EF (&bgr;=−0.28, P=0.012). In 68 patients examined after surgery, RV EF increased strongly (27.5±4.3–37.9±7.3, P<0.0001) in patients with depressed RV EF, whereas it did not change in others (P=0.91). RV EF ⩽35% impaired 10-year cardiovascular survival (71.6±8.4% versus 89.8±3.7%, P=0.037). Biventricular impairment dramatically reduced 10-year cardiovascular survival (51.9±15.3% versus 90.3±3.2%, P<0.0001; hazard ratio, 5.2; P<0.0001) even after adjustment for known predictors (hazard ratio, 4.6; P=0.004). Biventricular impairment reduced also 10-year overall survival (34.8±13.0% versus 72.6±4.5%, P=0.003; hazard ratio, 2.5; P=0.005) even after adjustment for known predictors (P=0.048). Conclusions— In patients with organic mitral regurgitation referred to surgery, RV function impairment is frequent (30%) and depends weakly on pulmonary artery systolic pressure but mainly on left ventricular remodeling and septal function. RV function is a predictor of postoperative cardiovascular survival, whereas biventricular impairment is a powerful predictor of both cardiovascular and overall survival.

156: Prevalence, determinants and prognosis value of right ventricular function impairment in organic mitral regurgitation

Objectives Pevalence, determinants and prognosis value of right ventricular (RV) ejection fraction (EF) in organic mitral regurgitation (MR). Methods Two-hundred eight pts (62±13 years, 138 males, AF 57 pts) with organic MR referred to surgery underwent an echocardiography and left ventricular (LV) and RV radionuclide angiography. LV and RV regional function was assessed. Results Mean RV EF was 40.7±10.1%, ranging from 10 to 65%. Sixty pts (29%) had a RV EF ≤35%. In multivariate analysis, LV septal function (LV EF 8: β=0.56, P 35% (46.0±6.9 to 46.1±8.2, P=0.91). Independent predictors of postoperative RV EF were preoperative RV EF (β=0.32, P=0.013) and TR ≥grade 2 (β=–0.22, P=0.036) while LV septal function (LV EF 8, β=0.24, P=0.069) was marginally predictive. Fifty-seven pts died during post-operative follow-up of 7.1±4.3 years. Pts with RV EF ≤35% compared with RVEF>35% had a similar survival rate at 10 years (63.6±8.7% versus 68.8±5.3%, P=0.68), but cardiovascular mortality was higher (25.3±8.0% versus 8.1±3.5%, P=0.03; HR=2.67, 95% CI 1.06-6.76, P=0.037). RV EF was not a predictive factor of operative mortality. In a Cox model, NYHA class, CABG, and left atrial diameter, but not RV EF, were independent predictors of overall mortality. Conclusion In organic MR RV function depends not only on PASP but mainly on LV remodeling and septal function, and improves strongly after surgery. RV EF is a predictor of cardiovascular mortality in univariate but not in multivariate analysis. Hence, impaired RV EF before surgery is not a sufficient argument to deny surgery in patients with organic MR.