E. Brochet

Tricuspid valve and percutaneous approach: No longer the forgotten valve!

Tricuspid valve disease is mainly represented by tricuspid regurgitation (TR), which is a predictor of poor outcome. TR is usually secondary, caused by right ventricle pressure or volume overload, the leading cause being left-sided heart valve diseases. Tricuspid surgery for severe TR is recommended during left valve surgery, and consists of either a valve replacement or, most often, a tricuspid repair with or without prosthetic annuloplasty. When TR persists or worsens after left valvular surgery, redo isolated tricuspid surgery is associated with high mortality. In addition, a sizeable proportion of patients present with tricuspid surgery deterioration over time, and need a reintervention, which is associated with high morbi-mortality rates. In this context, and given the recent major breakthrough in the percutaneous treatment of aortic and mitral valve diseases, the tricuspid valve appears an appealing challenge, although it raises specific issues. The first applications of transcatheter techniques for tricuspid valve disease were valve-in-valve and valve-in-ring implantation for degenerated bioprosthesis or ring annuloplasty. Some concerns remain regarding prosthesis sizing, rapid ventricular pacing and the best approach, but these procedures appear to be safe and effective. More recently, bicuspidization using a transcatheter approach for the treatment of native tricuspid valve has been published, in two patients. Finally, other devices are in preclinical development.

An unusual cause of pacemaker-induced severe tricuspid regurgitation

Pacemaker (PM) induced tricuspid regurgitation (TR) is a common echocardiographic finding. Although mild or moderate TR is frequently observed, severe TR is rare. We report the exceptional observation of a severe TR due to leaflet malcoaptation occurring late after PM implantation and in the following weeks after an aortic valve replacement. Our hypothesis is that the aortic valve surgery has been responsible for conformational changes between cardiac cavities, tricuspid valve and PM leads resulting in a severe TR.

Relationship Between Valve Calcification and Long-Term Results of Percutaneous Mitral Commissurotomy for Rheumatic Mitral Stenosis

Background—Indications of percutaneous mitral commissurotomy (PMC) remain debated in calcific mitral stenosis. We analyzed long-term results of PMC for calcific mitral stenosis and the factors associated with late functional results. Methods and Results—We compared the characteristics and outcome of 314 patients undergoing PMC for calcific mitral stenosis with 710 patients with noncalcified valves followed up to 20 years. Calcification was defined by fluoroscopy, and its extent was graded from 1 to 4. Good immediate results (valve area ≥1.5 cm2 with mitral regurgitation ⩽2/4) were obtained in 251 patients (80%) with calcified valves and 661 (93%) with noncalcified valves (P<0.001). The hazard ratio for good functional results (survival without cardiovascular death, without mitral reintervention, and in New York Heart Association class I or II) was 2.5 (95% confidence interval [2.1–2.9]; P<0.0001) in patients with calcified valves (12±3% at 20 years) relative to the noncalcified group (38±2% at 20 years). In the 251 patients with calcified valves who had good immediate results, 15-year rates of good functional results were 35±4% for minor (grade 1) calcification, 24±6% for grade 2, and 10±6% for severe (grades 3–4) calcification. Factors associated with poor late functional results on multivariable analysis were calcification extent, older age, higher New York Heart Association class, atrial fibrillation, and higher mean gradient after PMC. Conclusions—Although late results of PMC are less satisfying in calcific mitral stenosis, long-term functional outcome depends on calcification extent, patient characteristics, and immediate results of PMC. These findings support the use of PMC as first-line treatment in selected patients with calcific mitral stenosis.

Lipomatous Hypertrophy of the Inter-Atrial Septum and Stroke

An 80-year-old woman was admitted to our hospital for acute left homonymous hemianopia with upper left limb ataxia. The patient’s medical history was remarkable for hypertension, non-insulin-dependent diabetes mellitus and permanent atrial fibrillation confirmed by electrocardiogram on admission. There was no history of any type of cardiorespiratory disease and the patient was not treated with anticoagulants prior to admission to the hospital. Magnetic resonance imaging (MRI) of the brain revealed acute infarction in the right posterior cerebral artery territory. Transthoracic echocardiography showed a mass inside the left atrial appendage. The left ventricular systolic function and wall motion were normal, and there was no atrial distension or cardiac valves disease. Transesophageal echocardiography showed a thrombus (2.83 ! 1.5 cm) in the left atrial appendage (which was the likely cause of the stroke) and a hyperechogenic mass over the atrial septum suggesting lipomatous hypertrophy (length 1.38 cm). The patient was treated warfarin, and the clinical evolution was favorable. Lipomatous hypertrophy of the interauricular septum (IAS) is a benign cardiac tumor of unusual presentation. It is made up of an abnormal accumulation of non-encapsulated fatty tissue within the atrial septum. The diagnosis can be made with echocardiography, CT scan or MRI. Studies have found an association between this anomaly, increasing age and diabetes mellitus [1]. In most patients, this condition is completely asymptomatic but it may predispose to the development of atrial arrhythmias and conduction disturbances. Although a possible link between this abnormality and stroke cannot be ruled out, this finding has only been reported in 1 published case of stroke [2]. The most plausible cause of atrial fibrillation seen in our patient is the lipomatous hypertrophy of the IAS, since no cardiac disease was noted and supraventricular arrhythmias have been recognized in approximately half of the patients in whom this abnormalFig. 1. Transesophageal echocardiography showing a homogeneous hyperechoic mass of the atrial septum suggesting lipomatous hypertrophy of the atrial septum.

close: Closure of patent foramen ovale, oral anticoagulants or antiplatelet therapy to prevent stroke recurrence: Study design.

Rationale Currently available data do not provide definitive evidence on the comparative benefits of closure of patent foramen ovale, oral anticoagulants and antiplatelet therapy in patients with patent foramen ovale-associated cryptogenic stroke Aim To assess whether transcatheter patent foramen ovale closure plus antiplatelet therapy is superior to antiplatelet therapy alone and whether oral anticoagulant therapy is superior to antiplatelet therapy, for secondary stroke prevention in patients aged 16 to 60 years with a large patent foramen ovale or a patent foramen ovale associated with an atrial septal aneurysm, and an otherwise unexplained ischaemic stroke or retinal ischaemia. Sample size Six hundred and sixty-four patients were included in the study. Methods and design CLOSE is an academic-driven, multicentre, randomized, open-label, three-group, superiority trial with blinded adjudication of outcome events. The trial has been registered with Clinical Trials Register (Clinicaltrials.gov, NCT00562289). Patient recruitment started in December 2007. Patient follow-up will continue until December 2016. Expected mean follow-up = 5.6 years. Study outcomes The primary efficacy outcome is the occurrence of fatal or nonfatal stroke. Safety outcomes include fatal, life-threatening or major procedure- or device-related complications and fatal, life-threatening or major haemorrhagic complications. Discussion CLOSE is the first specifically designed trial to assess the superiority of patent foramen ovale closure over antiplatelet therapy alone and the superiority of oral anticoagulants over antiplatelet therapy to prevent stroke recurrence in patients with patent foramen ovale-associated cryptogenic stroke.

Eclipsed mitral regurgitation: an unusual cause of acute heart failure

Aims So far, a total of five patients with eclipsed mitral regurgitation (MR) have been reported in the literature by three different teams. The aim of this article was to detail clinical and echocardiographic characteristics, and outcome of patients presenting eclipsed MR. Methods and results We defined eclipsed MR as spontaneous appearance, at rest, from 1 min to the next of an acute restriction in the motion of mitral leaflets preventing coaptation and leading to massive MR in patients with normal left ventricular end-diastolic diameter, left ventricular ejection fraction >45%, and baseline MR ≤2. Spontaneous regression occurred within 30 min, and no obvious trigger such as acute hypertension, new-onset arrhythmia, or myocardial ischaemia is present. Clinical data, ECG, echocardiographic data, surgery report, and follow-up status of six patients with eclipsed MR are reported: all were post-menopausal women with median age of 74 [57-80] years presenting hypertension (4/6), chronic kidney disease (5/6), or chronic anaemia (4/6). Five out of six patients experienced acute pulmonary oedema requiring hospitalization and underwent mitral valve replacement because of heart failure recurrence. Two patients died in the first days after surgery while the three others are free of symptoms at, respectively, 56, 18, and 10 months follow-up. Conclusion Eclipsed MR is a clinical and echocardiographic syndrome responsible for heart failure with preserved EF. It is presently underdiagnosed and should be evoked in cases of recurrent acute pulmonary oedema without obvious trigger, in particular in patients presenting discordant evaluation of MR severity over time.

Early and late outcomes after trans-catheter aortic valve implantation in patients with previous chest radiation

Objective Surgery for aortic stenosis in patients with thoracic radiation therapy is associated with high morbi-mortality. Trans-catheter aortic valve implantation (TAVI) represents an alternative but has never been studied in this population. We aimed to compare outcomes in radiation and matched control patients undergoing TAVI and to identify predictive factors of survival. Methods Between 2006 and 2011, 288 consecutive patients underwent TAVI in our institution, of whom 26 had previous chest radiation. They were matched 1:1 for age, sex and TAVI approach with controls. Results In both groups, median age was 73 years, 50% of patients were male and 15% had a transapical approach. Procedural success was 88% in the radiation group versus 100% in controls (p<0.001) and 30-day survival was 92% in both groups. Five-year survival was 33%±10% in the radiation group and 42%±11% in controls (p=0.26). In radiation patients, the main cause of death was respiratory insufficiency in 40%. We identified four independent predictive factors of death in the radiation group: extracardiac arteriopathy (p=0.002) and the absence of β-blocker therapy (p=0.005) as preprocedural variables, and infectious complications (p=0.009) and a higher peak creatinine level (p=0.009) as postprocedural variables. In the radiation group, 89% of survivors were in New York Heart Association class I–II at last follow-up. Conclusions Patients in the radiation group displayed high mortality rates although not significantly different from the controls. Respiratory failure was the main cause of death, emphasising the need for a careful pulmonary evaluation. Finally, we show a sustained improvement in functional results after TAVI in this population.

Bailout transcatheter closure of patent foramen ovale for refractory hypoxaemia after left ventricular assist device implantation

We describe the interdisciplinary management of a 59-year old man with ischaemic cardiomyopathy on a HeartMate II left ventricular assist device (LVAD) and temporary right extracorporeal membrane oxygenation (ECMO) as a bridge-to-heart transplantation. He suffered refractory hypoxaemia due to massive right-to-left shunting by a patent foramen ovale (PFO), diagnosed after weaning off of temporary right ECMO. Percutaneous closure of the PFO was successfully achieved with an Amplatzer septal occluder device, which allowed the patients extubation and departure from hospital. The patient received heart transplantation 7 weeks after LVAD implantation and was discharged from the intensive care unit 2 weeks after transplantation.

Optimization of patent foramen ovale detection by contrast transthoracic echocardiography using harmonic imaging

The pathological role of patent foramen ovale (PFO) is increasingly suggested in a number of clinical situations such as paradoxical embolism, refractory hypoxaemia, platypnoea-orthodeoxia syndrome, decompression sickness in divers, and migraine with aura and stroke. The association between PFO and cryptogenic stroke has been recognized for many years and confirmed in a recent meta-analysis [1]. Therapeutic trials are ongoing to test prospectively the safety and efficacy of PFO closure techniques or medical therapy for stroke recurrence. Because of these potential therapeutic implications, accurate identification of PFO is crucial. However, the best way to identify PFO remains the subject of debate [2]. Although the cornerstone of diagnosis of PFO is the identification of right-to-left shunt after contrast injection, different imaging techniques are proposed such as transoesophagea l echocard iography (TEE) , t ransthorac ic echocardiography (TTE) and transcranial Doppler (TCD). In this issue of the journal, Lefevre et al [3] studied, with contrast harmonic TTE (HTTE) and TEE, 121 patients referred for detection of PFO. They compared the performance of three randomized contrast agents: a mixture of dextrose and air (DA); dextrose, air and blood (DAB); and hydroxyethylamidon (HEA). Identification of PFO was studied both semiquantitatively and quantitatively using video densitometry. Their study addresses several important issues concerning PFO detection. What is the best technique to detect a PFO: TEE or TTE?

Comparisons of the new EuroSCORE II with the logistic EuroSCORE and the Society of Thoracic Surgeons score – implications for transcatheter aortic valve implantation

Background.— The logistic EuroSCORE (logES) and the Society of Thoracic Surgeons (STS) scores are commonly used to select highrisk patients for Transcatheter Aortic Valve Implantation (TAVI) but their validity in patients with valvular heart disease has been questioned. The EuroSCORE II (ESII) was elaborated to improve risk assessment but comparisons with logES and STS scores are rare and no threshold has been proposed to define high-risk patients. Methods.— In 272 patients with severe symptomatic aortic stenosis who underwent a TAVI at our institution we compared the three scores. Results.— The ESII was lower and moderately correlated to the logES (9 ± 8% vs. 23 ± 14%, P < 0.01; r = 0.61, P < 0.001) and not different but poorly correlated to the STS (10 ± 9%, P = 0.10; r = 0.25, P < 0.001). Based on recommended thresholds defining high-risk patients (LogES ≥ 20% or STS ≥ 10%), area under the curve of the ROC analysis was 0.81 for the logES and 0.67 for the STS and an ESII of 7% provided the best diagnostic value. However, contingency analyses showed that agreement between the ESII and the logES was moderate (kappa = 0.44) with a risk assessment different in 76 patients (28%) and agreement with the STS score was poor (kappa = 0.27) with a risk assessment different in 99 patients (36%). Conclusions.— A ESII threshold of 7% may be used to identify highrisk patients but correlations and agreements between the scores were only modest. Our results highlight the limits of current scoring systems and reinforce the ESC Guidelines stressing the importance of the clinical judgment of a heart team in addition to a combination of scores team in addition to a combination of scores.