Frédéric Poulin

Excellent outcomes for transcatheter aortic valve replacement within 1 year of opening a low-volume centre and consideration of requirements.

BACKGROUND After the approval of transcatheter aortic valve replacement (TAVR) for high-risk or inoperable patients with severe aortic stenosis (AS), many low- and moderate-volume TAVR programs were initiated. Contemporary outcomes from these newly initiated centres remain unknown. METHODS In March 2013, our institution was authorized by the Québec Ministry of Health to perform 30 TAVR procedures. After thorough clinical screening and imaging evaluation, suitable patients underwent transfemoral TAVR with the balloon-expandable SAPIEN XT (Edwards Lifesciences, Irvine, CA) transcatheter heart valve (THV). In-hospital and 30-day outcomes were prospectively collected and reported according to Valve Academic Research Consortium 2 guidelines. RESULTS From April 2013 to January 2014, 30 consecutive high-risk (n = 16 [53.3%]) or inoperable (n = 14 [46.7%]) patients (mean age, 84.6 years; mean Society of Thoracic Surgery score, 7) with symptomatic severe AS underwent transfemoral TAVR. No catastrophic intraprocedural complications such as annulus rupture, valve embolization, aortic dissection, or coronary occlusion occurred, and there were no deaths at 30 days. Disabling stroke occurred in 1 (3.3%) patient 48 hours after THV implantation. Major vascular complications and major bleeding occurred in 1 (3.3%) patient. No moderate or severe paravalvular leak was observed. The median length of stay was 2 (1-3) days, with 8 (26.7%) patients discharged within 24 hours after the procedure. CONCLUSIONS Excellent outcomes can be achieved in newly initiated relatively low-volume centres, which compares favorably to previously published large series. Important considerations include appropriate team training, rigorous patient screening, use of multimodality imaging techniques, a heart team approach, constant integration of lessons learned from larger published experiences, and maintaining a recommended minimum volume of 25 cases per year.

Right Ventricular Dysfunction in Patients Experiencing Cardiotoxicity during Breast Cancer Therapy

Background. Right ventricular (RV) dysfunction during cancer therapy related cardiotoxicity and its prognostic implications have not been examined. Aim. We sought to determine the incidence and prognostic value of RV dysfunction at time of LV defined cardiotoxicity. Methods. We retrospectively identified 30 HER2+ female patients with breast cancer treated with trastuzumab (± anthracycline) who developed cardiotoxicity and had a diagnostic quality transthoracic echocardiography. LV ejection fraction (LVEF), RV fractional area change (RV FAC), and peak systolic longitudinal strain (for both LV and RV) were measured on echocardiograms at the time of cardiotoxicity and during follow-up. Thirty age balanced precancer therapy and HER2+ breast cancer patients were used as controls. Results. In the 30 patients with cardiotoxicity (mean ± SD age 54 ± 12 years) RV FAC was significantly lower (42 ± 7 versus 47 ± 6%, P = 0.01) compared to controls. RV dysfunction defined by global longitudinal strain (GLS < −20.3%) was seen in 40% (n = 12). During follow-up in 16 out of 30 patients (23 ± 15 months), there was persistent LV dysfunction (EF < 55%) in 69% (n = 11). Concomitant RV dysfunction at the time of LV cardiotoxicity was associated with reduced recovery of LVEF during follow-up although this was not statistically significant. Conclusion. RV dysfunction at the time of LV cardiotoxicity is frequent in patients with breast cancer receiving trastuzumab therapy. Despite appropriate management, LV dysfunction persisted in the majority at follow-up. The prognostic value of RV dysfunction at the time of cardiotoxicity warrants further investigation.

von Willebrand Disease After TAVR: The Missing Link?

By abolishing the obstruction created by a highly stenotic aortic valve, transcatheter aortic valve replacement (TAVR) is an effective treatment for severe aortic stenosis, with a hemodynamic profile (mean gradient and aortic valve area) at least similar or even superior to conventional surgical

Transcatheter Aortic Valve Replacement in a Patient With a Previous Bioprosthetic Mitral Valve Replacement: Report of a Delayed Fatal Interaction

We report on a man with bioprosthetic mitral valve perforation who presented late after transcatheter aortic valve replacement with a balloon-expandable transcatheter heart valve (THV). The protrusion of the commissural strut of the bioprosthetic mitral valve coupled with the low implanted THV resulted in repetitive trauma leading to rupture of a mitral leaflet. Potential preventive strategies are discussed. This case illustrates the importance of preprocedural imaging screening and cautious THV deployment in patients with a bioprosthetic mitral valve.

Early Hemodynamic Results in Patients With Small Aortic Annulus After Aortic Valve Replacement

Objective Patients with a small aortic annulus (≤21 mm) have an increased risk of patient-prosthesis mismatch after valve replacement. The aim of this study was to compare the early hemodynamic performance of the balloon-expandable transaortic valve implantation Edwards system (SAPIEN) and the sutureless Perceval prostheses. Methods Fifty patients underwent transcatheter aortic valve implantation, and 113 patients underwent sutureless aortic valve replacement. Mean ± SD aortic annulus diameter was 19.7 ± 1 mm, with no significant difference between groups. SAPIEN valve size was 23 mm in 40 patients (80%) and 26 mm in 10 patients (20%). Perceval valve size was small in 45 patients (40%), medium in 62 patients (55%), and large in 6 patients (5%). Transthoracic Doppler echocardiographic images were collected at baseline and before discharge. Results There were no significant difference in predischarge effective orifice area (SAPIEN: 1.5 ± 0.5 cm2 and Perceval: 1.48 ± 0.34 cm2, P = 0.58) and indexed effective orifice areas (SAPIEN: 0.93 ± 0.32 cm2/m2 and Perceval: 0.88 ± 0.22 cm2/m2, P = 0.42). Predischarge mean ± SD transaortic gradient was lower with the SAPIEN than with Perceval valves (12 ± 6 and 17 ± 6 mm Hg, respectively, P < 0.001). Rates of moderate and severe prosthesis-patient mismatch were similar (SAPIEN: 44% and 10% and Perceval: 50% and 14%, P = 0.53 and 0.75, respectively). There were no moderate-severe paravalvular leaks. Conclusions Although indexed effective orifice areas were similar, transcatheter aortic valve implantation with the balloon-expandable SAPIEN system yielded lower predischarge transaortic mean gradients than the surgically implanted Perceval, in patients with a small annulus.

Severe Asymptomatic Unicuspid Aortic Stenosis, Myocardial Fibrosis, and Sudden Death: Relevance of Multimodality Imaging

Graphical abstract

Late Cardiac Death in Patients Undergoing Transcatheter Aortic Valve Replacement

In the PARTNER (Placement of Aortic Transcatheter Valve Trial) study, similar to other studies, mild, moderate, or severe aortic regurgitation (AR) after transcatheter aortic valve replacement (TAVR) was associated with 1-year, all-cause mortality [(1)][1]. In the February 10, 2015, issue of the

von Willebrand Disease After TAVR

By abolishing the obstruction created by a highly stenotic aortic valve, transcatheter aortic valve replacement (TAVR) is an effective treatment for severe aortic stenosis, with a hemodynamic profile (mean gradient and aortic valve area) at least similar or even superior to conventional surgical

Letter to the Editorvon Willebrand Disease After TAVR: The Missing Link?

By abolishing the obstruction created by a highly stenotic aortic valve, transcatheter aortic valve replacement (TAVR) is an effective treatment for severe aortic stenosis, with a hemodynamic profile (mean gradient and aortic valve area) at least similar or even superior to conventional surgical

TRANSCATHETER AORTIC VALVE IMPLANTATION IMPROVES LEFT VENTRICULAR MYOCARDIAL MECHANICS IN NORMAL AND ABNORMAL LEFT VENTRICULAR FUNCTION

Aortic stenosis (AS) induces chronic pressure overload on the left ventricle (LV) with alterations in myocardial structure and function. We aimed to study the impact of transcatheter aortic valve implantation (TAVI) on the recovery of myocardial mechanics and the influence of post-procedural aortic