Bertrand Marcheix

Thirty-day outcome and vascular complications after transarterial aortic valve implantation using both Edwards Sapien and Medtronic CoreValve bioprostheses in a mixed population.

AIMSnTranscatheter aortic valve implantation (TAVI) is performed through a transarterial approach with encouraging results in one-type valve registries. We report 30-day data from a mixed population of patients treated with either Medtronic CoreValve (MCV) or Edwards SAPIEN (ES) valves.nnnMETHODS AND RESULTSnForty-five patients had TAVI via the transarterial approach (21 MCV and 24 ES). Mean age was 81.8+/-4.2 years, Logistic EuroSCORE was 25.2+/-8.4%. Procedural success rate was 97.8%. In-hospital death rate was 4.4%. Vascular complication rate was 8.9%. Of MCV patients, 28.6% had a permanent pacemaker vs. 4.2% of ES patients; p=0.02. No additional deaths were observed between discharge and 30 days. NYHA functional class was improved at 30-days: 2.07+/-0.4 vs. 3.09+/-0.05, p<0.0001. Mean transvalvular gradient was lower: 9.5+/-3.28 mmHg vs. 41.9+/-14 mmHg, p<0.0001. Overall 30-day MACE rate was 8.9%, similar between MCV and ES patients.nnnCONCLUSIONnA routine policy of TAVI using both MCV and ES valves is feasible without any worsening of procedural success rates and 30-day outcomes. A wider population of high risk patients with aortic stenosis can be offered a transarterial treatment. This could be the next standard of care for teams performing TAVI.

Adverse impact of bleeding and transfusion on the outcome post-transcatheter aortic valve implantation: Insights from the Pooled-RotterdAm-Milano-Toulouse In Collaboration Plus (PRAGMATIC Plus) initiative

BACKGROUNDnLittle is known about the impact of bleeding and red blood cells transfusion (RBC) on the outcome post transcatheter aortic valve implantation (TAVI).nnnMETHODSnBetween November 2005 and August 2011, 943 consecutive patients underwent TAVI. Bleeding was assessed according to the Valve Academic Research Consortium definitions. Patients receiving RBC were compared to those not requiring transfusion.nnnRESULTSnLife-threatening and major bleedings occurred respectively in 13.9% and 20.9% of the patients, significantly more frequently in the RBC cohort. Vascular complications occurred in 23.2% of the patients. Major and minor vascular complications were more frequent in the RBC group: 19.3 vs 5.2%, P < .001; 15.3 vs 9%, P = .003, respectively. Thirty-day all-cause mortality was 7.2%. Of the overall cohort, 38.9% required RBC transfusion; those receiving at least 4 U of RBC had higher 30-day all-cause mortality than those receiving 1 to 4 U of RBC and those not requiring transfusion: 14.4%, vs 6.3% vs 6.3%, respectively, P = .008. By multivariate analysis, transfusion of RBC was associated with an increased 30-day and 1-year mortality. Major stroke and all stages of acute kidney injury were significantly more frequent in the RBC cohort.nnnCONCLUSIONSnBleeding is frequent after TAVI, mainly driven by vascular complications. RBC transfusion was associated with increased mortality at 1 year and increased risk of major stroke and acute kidney injury. Specific scores are needed to identify the patients at higher risk for TAVI-related bleeding and RBC transfusion.

Desensitization of Platelet-Derived Growth Factor Receptor-β by Oxidized Lipids in Vascular Cells and Atherosclerotic Lesions. Prevention by Aldehyde Scavengers

The platelet-derived growth factor receptor-&bgr; (PDGFR&bgr;) signaling pathway regulates smooth muscle cell (SMC) migration and proliferation and plays a role in the vascular wall response to injury. Oxidized low-density lipoprotein (oxLDL) in atherosclerotic lesions can activate the PDGFR&bgr; pathway, but the long-term effects of oxLDL on PDGFR&bgr; function are not well understood. We found that oxLDL induced a dual effect on PDGFR&bgr; signaling. Initial activation of the PDGFR was followed by desensitization of the receptor. PDGFR&bgr; desensitization was not attributable to PDGFR&bgr; degradation or changes in localization to the caveolae but instead resulted from decreased PDGF binding and inhibition of PDGFR&bgr; tyrosine kinase activity. This inhibition was associated with formation of (4HNE)– and acrolein–PDGFR&bgr; adducts and was mimicked by preincubation of cells with 4HNE. These PDGFR&bgr; adducts were also detected in aortae of apolipoprotein-deficient mice and hypercholesterolemic rabbits and in human carotid plaques. The aldehyde scavengers DNPH and Hydralazine prevented both oxLDL- and 4HNE-induced structural modification and PDGFR&bgr; signaling dysfunction in cells and in vivo. OxLDL inhibition of PDGF signaling may contribute to defective SMC proliferation and decrease the stability of a vulnerable plaque.

Trends in outcome after transfemoral transcatheter aortic valve implantation

BACKGROUNDnTransfemoral transcatheter aortic valve implantation (TF-TAVI) is a viable and safe treatment strategy for patients with symptomatic severe aortic stenosis and high operative risk and has been introduced as such in the recently updated European guidelines on the management of valvular heart disease.Our aim was to assess trends in outcome after TF-TAVI.nnnMETHODSnPropensity score-matched analysis of a multicenter registry of consecutive patients undergoing TF-TAVI subdivided into 3 tertiles based on enrollment date was performed. Three tertiles of 214 propensity score-matched patients were compared.nnnRESULTSnWith mounting experience and moving from the initial to the last cohort, procedural contrast volume and radiation time decreased. Over time, there were less major vascular complications (15% vs 7.9%, P = .023), life-threatening bleedings (17.8% vs 7.9%, P = .003), and major bleedings (22.4% vs 12.1%, P = .007). Major vascular complications and life-threatening bleedings caused by closure device failure decreased significantly (9.2% vs 3.1% [P = .01] and 5.7% vs 1 % [P = .01], respectively). The combined safety end point dropped from 31.3% in tertile (T) (T1) to 17.8% in T3 (P < .001). By multivariable analysis, the last cohort as compared with the initial cohort was associated with significant reductions in 30-day mortality (odds ratio [OR] 0.35, 95% CI 0.12-0.96), stage 3 AKI (OR 0.12, 95% CI 0.29-0.93), and the combined safety end point (OR 0.52, 95% CI 0.29-0.93). One-year survival improved significantly (T1 79% vs T3 86%, P = .016).nnnCONCLUSIONSnOver time, TAVI is performed with significant reductions in major vascular complications, life-threatening bleedings, and the combined clinical safety end point and improved 1-year survival.

TRPC1 is regulated by caveolin-1 and is involved in oxidized LDL-induced apoptosis of vascular smooth muscle cells.

Oxidized low‐density lipoprotein (oxLDL) induced‐apoptosis of vascular cells may participate in plaque instability and rupture. We have previously shown that vascular smooth muscle cells (VSMC) stably expressing caveolin‐1 were more susceptible to oxLDL‐induced apoptosis than VSMC expressing lower level of caveolin‐1, and this was correlated with enhanced Ca2+ entry and pro‐apoptotic events. In this study, we aimed to identify the molecular events involved in oxLDL‐induced Ca2+ influx and their regulation by the structural protein caveolin‐1. In VSMC, transient receptor potential canonical‐1 (TRPC1) silencing by ARN interference prevents the Ca2+ influx and reduces the toxicity induced by oxLDL. Moreover, caveolin‐1 silencing induces concomitant decrease of TRPC1 expression and reduces oxLDL‐induced apoptosis of VSMC. OxLDL enhanced the cell surface expression of TRPC1, as shown by biotinylation of cell surface proteins, and induced TRPC1 translocation into caveolar compartment, as assessed by subcellular fractionation. OxLDL‐induced TRPC1 translocation was dependent on actin cytoskeleton and associated with a dramatic rise of 7‐ketocholesterol (a major oxysterol in oxLDL) into caveolar membranes, whereas the caveolar content of cholesterol was unchanged. Altogether, the reported results show that TRPC1 channels play a role in Ca2+ influx and Ca2+ homeostasis deregulation that mediate apoptosis induced by oxLDL. These data also shed new light on the role of caveolin‐1 and caveolar compartment as important regulators of TRPC1 trafficking to the plasma membrane and apoptotic processes that play a major role in atherosclerosis.

The anterior intermeniscal ligament of the knee: an anatomic and MR study

BackgroundThe purposes of this study were to identify the presence of the anterior intermeniscal ligament of the knee (AIL), to study its attachment patterns and relationships to other anatomic structures within the knee and to evaluate the potential association of its rupture with other pathology of the knee.MethodsTen human cadaver knees were dissected excluding knees with surgical scars. Fifty-one MR examinations were performed in symptomatic patients. Arthroscopic observations were carried out on ten patients.ResultsAIL was found in nine dissected knees with type I insertion in six cases, type II insertion in three cases. The average length was 31.2xa0mm (25–45xa0mm). The average distance between AIL and insertion of the anterior cruciate ligament was 12xa0mm (11–15xa0mm). Concerning MR study, AIL was found in 34 cases (82.9%). Four (9.75%) ruptures of the AIL were encountered. Where AIL was intact, 14 patients presented meniscal lesions (46.6%). Where AIL was ruptured, three patients presented meniscal lesions (75%).ConclusionThe present study demonstrates through anatomical and MR studies that AIL is present in more than 80% of the cases with predominant type I insertion. The association of meniscal and AIL lesions was highlighted demonstrating that AIL is not only an anatomical point of interest but also a clinical and surgical reality.

Feasibility and accuracy of gated blood pool SPECT equilibrium radionuclide ventriculography for the assessment of left and right ventricular volumes and function in patients with left ventricular assist devices

BackgroundLeft ventricular assist devices (LVADs) require serial assessment of right and left ventricular (RV & LV) volumes and function. Because the RV is not assisted, its function is a critical determinant of the hemodynamic and contributes significantly to postoperative morbidity and mortality. We evaluated the feasibility and the accuracy of tomographic-equilibrium radionuclide ventriculography (t-ERV) for the assessment of patients with LVADs.MethodsTwenty-four patients with LVAD underwent t-ERV. Because of the limited acoustic window, transthoracic echocardiography (TTE) was only feasible in 19 patients. Functional evaluation including six-minute walk test (6MWT) and peak oxygen consumption (POC) was performed in 18 patients. Nine patients underwent a cardiac multidetector computed tomography (MDCT). Eight patients underwent a second evaluation by ERV 4.3xa0±xa01.4 months later.ResultsReliability between t-ERV and MDCT for LV end-diastolic volume, LV end-systolic volume, LV ejection fraction, RV end-diastolic volume, RV end-systolic volume, and RV ejection fraction (RVEF) was 0.900 (P = .001), 0.911 (P = .001), 0.765 (P = .021), 0.728 (P = .042), 0.875 (P = .004), and 0.781 (P = .023), respectively. There was no correlation between t-ERV and RV systolic parameters assessed by TTE. RVEF was correlated with POC (R = 0.521; P = .027). A cut-off value of 40% for RVEF measured by t-ERV could discriminate patients with poor functional status (P = .048 for NYHA stage; P = .016 for 6MWT and P = .007 for POC).Conclusiont-ERV is a simple, reproducible, and an accurate technique for the assessment of RV function in patients with LVADs and warrants consideration in the evaluation and monitoring of symptomatic patients.

165 Non-randomised comparison of 30-day safety and effectiveness of surgical aortic valve replacement and transcatheter aortic valve implantation for high risk patients with severe aortic stenosis

Purpose transcatheter aortic valve implantation (TAVI), performed either by transfemoral (TF) or transapical (TA) approach, is an emerging technique for the treatment of severe aortic stenosis (AS) in high-risk patients. It is unclear whether TF- or TA-TAVI compares favourably with modern conventional surgical aortic valve replacement (SAVR) in a high-risk population. Methods we conducted a two-centre observational prospective cohort study. High-risk patients (Logistic EuroScore 15% and/or STS Scorexa0>xa010%) with symptomatic severe AS were treated either by SAVR or by TAVI. TF approach was the first choice for TAVI, using both the balloon-expandable or the self-expandable available bioprostheses. TA approach was used when TF approach was contra-indicated. Baseline characteristics, 30-day functional status, prostheses mean gradient (MG) (efficacy endpoint), and 30-day allcause mortality (safety endpoint) were compared. Results 143 patients were included: 58 underwent SAVR, 60 underwent TF-TAVI and 25 TA-TAVI. Mean age, aortic valve area and left ventricular ejection fraction were the same in the 3 groups. Patients undergoing TF- and TA-TAVI had higher Logistic EuroScore (24.0% [20.0–29.0], 25.2% [20.0–29.8] vs 18.6% [15.8–23.8] respectively, pxa0=xa00.001) and worse functional status (NYHA classxa0>xa0or = III: 98%, 100% vs 50% respectively, pxa0 Conclusions These observational data suggest that, in this high-risk population, SAVR and TAVI 30-day effectiveness are equivalent. Only TF-TAVI, whereas no TA-TAVI when reserved to contraindications of TF approach, seems to improve the 30-day mortality in comparison with SAVR.

CV7 Traitement complementaire des stent-grafts aortiques thoraciques

Objectifs Le traitement par endoprothese isole peut etre insuffisant pour exclure definitivement une lesion de l’aorte thoracique. D’autres gestes endovasculaires peuvent etre essentiels pour completer cette therapeutique. Materiels et methodes Sur 173 patients traites par stent-graft thoracique, 17 ont necessite un geste complementaire : 3 femmes et 14 hommes de 58,1 +/−16 ans d’âge moyen, ont beneficie de 11 embolisations pour des fuites de type II, de 4 stents sous-claviers gauches dont 1 couvert et de 3 embolisations directes du faux chenal ou de l’anevrysme. Resultats Un succes technique a pu etre obtenu dans tous les cas, permettant d’eliminer les fuites secondaires et d’obtenir une thrombose complete de la lesion. Conclusion Les techniques endovasculaires complementaires sont souvent indispensables pour obtenir l’exclusion des lesions de l’aorte thoracique. Des difficultes techniques sont cependant frequentes.