Julien Dreyfus

Feasibility of percutaneous mitral commissurotomy in patients with commissural mitral valve calcification

AIMSnWhether a percutaneous mitral commissurotomy (PMC) should be attempted in patients with mitral stenosis (MS) and valvular calcification, especially located at the commissural level remained debated. We sought to evaluate the impact of the degree and location of mitral valve calcifications on PMC results.nnnMETHODS AND RESULTSnOver a 3-year period, we enrolled 464 consecutive patients who underwent a PMC at our institution. According to the location (within the body valve leaflets or at the commissural level) and the degree of calcification, patients were divided into three groups: 261 patients were in Group 1 (no leaflets or commissural calcification), 141 in Group 2 (leaflets calcification with no significant commissural calcification), and 62 in Group 3 (at least one commissure significantly calcified). Final valve area (1.83 ± 0.26, 1.71 ± 0.25, and 1.60 ± 0.24 cm(2), P < 0.00001) and the rate of complete opening of at least one commissure (92, 94, and 84%, P = 0.05) were significantly different. However, the rate of post-PMC mitral regurgitation (MR) of grade ≥ 3 (10, 10, and 8%, P = 0.90) was not different among the groups and if the rate of good immediate result, defined as valve area ≥ 1.5 cm(2) with no MR >2/4 was different among the three groups (88, 78, and 73%, P = 0.004), an overallprocedural success could be achieved in most patients with calcified commissures.nnnCONCLUSIONnIn this large contemporary series of patients with MS, a procedural success was obtained less frequently in patients with calcified commissure but a successful PMC could still be safely achieved in a large proportion of patients. Our results support the use of PMC as a first-line treatment of patients with severe MS even in the presence of significant commissural calcifications with otherwise favourable clinical characteristics.

Real-time 3D transoesophageal measurement of the mitral valve area in patients with mitral stenosis.

AIMSnPlanimetry measured by two-dimensional transthoracic echocardiography (TTE, MVA2D) is the reference method for the evaluation of the severity of mitral stenosis (MS) but requires experienced operators and good echocardiographic windows. Real-time three-dimensional transoesophageal echocardiography (3D-TEE, MVA3D) may overcome these limitations but its accuracy has never been evaluated.nnnMETHODS AND RESULTSnWe prospectively enrolled 80 patients (58±15 years, 86% female) referred for MS evaluation who underwent, within 1 week, a clinically indicated TTE and TEE. MVA2D was measured by experienced operators (Level III), MVA3D by one experienced and one non-experienced (Level I) operators blinded of any clinical or TTE information. MVA3D measured by the experienced operator [1.11±0.32 cm2; median, 1.1 cm2; range (0.45-2.20)] did not differ from and correlated well with MVA2D [1.10±0.34 cm2; median, 1.05 cm2; range (0.45-2.30)], P=0.87; r=0.79, P<0.0001; ICC=0.79) and mean difference between methods was small (+0.004±0.21 cm2). MVA3D measured by the non-experienced operator [1.08±0.34 cm2; median 1.02 cm2; range (0.45-2.23)] also did not differ from and correlated well with MVA2D measured by experienced operators (P=0.25; r=0.86, P<0.0001; mean difference -0.02±0.18 cm2; ICC=0.86). Intra and interobserver variability were 0.02±0.25 and 0.01±0.33 cm2.nnnCONCLUSIONn3D-TEE provides accurate and reproducible MVA measurements similar to 2D planimetry performed by experienced operators. Thus, 3D-TEE could be considered as a second-line alternative tool for the evaluation of MS severity in patients with poor echocardiographic windows or for team less accustomed to evaluate MS patients.

Disintegration of a stentless valved conduit causing contained rupture of the aortic root.

![Figure][1] nn[![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5]nnnnA 40-year-old-man required, in 2007, the implantation of a stentless valved conduit for destructive aortic endocarditis. In 2009, he presented with dyspnea and a new aortic regurgitation murmur, but no

115 Relation between global longitudinal strain in patients with aortic stenosis: relation with severity and symptoms

Background Patient with aortic stenosis (AS) and reduced ejection fraction (EF) should be promptly operated on. Global longitudinal strain (GLS) has been proposed as a subtle subclinical marker of left ventricular (LV) systolic dysfunction and a potential prognostic factor in asymptomatic patients with AS. However, the relation between GLS, AS severity and symptoms has not been fully evaluated. Methods Eighty-six patients (74xa0±xa011 years, 35% female) with at least mild AS were prospectively enrolled. Clinical evaluation included the assessment of symptoms (angina, syncope, and dyspnea) and a physical examination. All patients had a comprehensive transthoracic echocardiography (TTE). GLS was measured offline using a dedicated station and software (EchoPac, General Electric) blinded of any clinical and TTE information. Results Forty-three patients (43%) were asymptomatic. AS range was wide with a mean aortic valve area (AVA) of 1.06xa0±xa00.42xa0cm 2 [0.33–2.3] and 55 patients (64%) had a severe AS (AVA 2 ). Mean EF was 63xa0±xa06 and 8 patients (9%) and a reduced EF ( Conclusions In the present study we show that GLS was significantly correlated to AS severity and reduced in patients impaired EF. However, GLS was not different between patients with symptomatic and asymptomatic severe AS. These preliminary data deserve further confirmation but raise caution regarding the potential prognostic value of GLS in patients with asymptomatic AS. Group 1 (n xa0=xa0 31) Group 2 (n xa0=xa0 12) Group 3 (n xa0=xa0 35) Group 4 (n xa0=xa0 8) P between groups GLS −19,1xa0±xa02.9 −18,7xa0±xa04.6 −17.5xa0±xa03.2 −12.5xa0±xa04.0

117 Real-time 3D transoesophageal echocardiography evaluation of the mitral valve area in patients with mitral stenosis

Aims Planimetry measured by two-dimensional transthoracic echocardiography (TTE, MVA2D) is the reference method for the evaluation of the severity of mitral stenosis (MS) but is significantly less reliable when performed by non-experienced operators and when transthoracic echogenicity is poor. Real-time three-dimensional transoesophageal echocardiography (RT3DTEE, MVA3D) may overcome those limitations but its accuracy has never been evaluated. Methods We prospectively enrolled 43 patients (59xa0±xa015 years, 86% female) referred for MS evaluation who underwent the same day a TTE and a RT3DTEE. MVA2D was assessed by experienced operators, MVA3D was measured by one experienced (Level III) and one non-experienced operator (Level I) blinded of any clinical and TTE information. RT3DTEE images were digitally stored and analysed offline on a workstation using dedicated software (QLab, Philips) in a random order. MVA3D was measured at the best cross section of the mitral valve defined as the most perpendicular and smallest orifice. Results MVA3D measured by the experienced operator (1.07xa0±xa00.31xa0cm2 [range 0.45–1.85]) did not differ from and correlated well with MVA2D (1.08xa0±xa00.32xa0cm2 [range 0.54–2.00], pxa0=xa00.84, rxa0=xa00.71, pxa0 Conclusion RT3DTEE provides accurate and reproducible MVA measurements similar to 2D planimetry performed by experienced operators. Thus, RT3DTEE should be considered as an alternative tool for the evaluation of MS severity, especially in patients with poor echocardiographic windows or for team less accustomed to evaluate patients with MS.