Laurence Tafanelli

Survival Implication of Left Ventricular End-Systolic Diameter in Mitral Regurgitation Due to Flail Leaflets : A Long-Term Follow-Up Multicenter Study

OBJECTIVES This study analyzed the association of left ventricular end-systolic diameter (LVESD) with survival after diagnosis in organic mitral regurgitation (MR) due to flail leaflets. BACKGROUND LVESD is a marker of left ventricular function in patients with organic MR but its association to survival after diagnosis is unknown. METHODS The MIDA (Mitral Regurgitation International Database) registry is a multicenter registry of echocardiographically diagnosed organic MR due to flail leaflets. We enrolled 739 patients with MR due to flail leaflets (age 65 +/- 12 years; ejection fraction: 65 +/- 10%) in whom LVESD was measured (36 +/- 7 mm). RESULTS Under conservative management, 10-year survival and survival free of cardiac death were higher with LVESD <40 mm versus > or =40 mm (64 +/- 5% vs. 48 +/- 10%; p < 0.001, and 73 +/- 5% vs. 63 +/- 10%; p = 0.001). LVESD > or =40 mm independently predicted overall mortality (hazard ratio [HR]: 1.95, 95% confidence interval [CI]: 1.01 to 3.83) and cardiac mortality (HR: 3.09, 95% CI: 1.35 to 7.09) under conservative management. Mortality risk increased linearly with LVESD >40 mm (HR: 1.15, 95% CI: 1.04 to 1.27 per 1-mm increment). During the entire follow-up (including post-surgical), LVESD > or =40 mm independently predicted overall mortality (HR: 1.86, 95% CI: 1.24 to 2.80) and cardiac mortality (HR: 2.14, 95% CI: 1.29 to 3.56), due to persistence of excess mortality in patients with LVESD > or =40 mm after surgery (HR: 1.86, 95% CI: 1.11 to 3.15 for overall death, and HR: 1.81, 95% CI: 1.05 to 3.54 for cardiac death). CONCLUSIONS In MR due to flail leaflets, LVESD > or =40 mm is independently associated with increased mortality under medical management but also after mitral surgery. These findings support prompt surgical rescue in patients with LVESD > or =40 mm but also suggest that best preservation of survival is achieved in patients operated before LVESD reaches 40 mm.

Outcomes in Mitral Regurgitation Due to Flail Leaflets: A Multicenter European Study

OBJECTIVES The purpose of this study was to assess incidence and predictors of events associated with nonsurgical and surgical management of severe mitral regurgitation (MR) in European institutions. BACKGROUND The management of patients with MR remains disputed, warranting multicenter studies to define clinical outcome in routine clinical practice. METHODS The MIDA (Mitral Regurgitation International DAtabase) is a registry created for multicenter study of MR with echocardiographically diagnosed flail leaflet as a model of pure, organic MR. Our cases were collected from 4 European centers. We enrolled 394 patients (age 64 +/- 11 years; 67% men; 64% in New York Heart Association functional class I to II; left ventricular ejection fraction 67 +/- 10%). RESULTS During a median follow-up of 3.9 years, linearized event rates/year under nonsurgical management were 5.4% for atrial fibrillation (AF), 8.0% for heart failure (HF), and 2.6% for death. Mitral valve (MV) surgery was performed in 315 (80%) patients (repair in 250 of 315, 80%). Perioperative mortality, defined as death within 30 days from the operation, was 0.7% (n = 2). Surgery during follow-up was independently associated with reduced risk of death (adjusted hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.21 to 0.84; p = 0.014). Benefit was largely driven by MV repair (adjusted HR vs. replacement 0.37, 95% CI 0.18 to 0.76; p = 0.007). In 102 patients strictly asymptomatic and with normal ventricular function, 5-year combined incidence of AF, HF, or cardiovascular death (CVD) was 42 +/- 8%. In these patients, surgery also reduced rates of CVD/HF (HR 0.26, 95% CI 0.08 to 0.89; p = 0.032). CONCLUSIONS In this multicenter study, nonsurgical management of severe MR was associated with notable rates of adverse events. Surgery especially MV repair performed during follow-up was beneficial in reducing rates of cardiac events. These findings support surgical consideration in patients with MR due to flail leaflets for whom MV repair is feasible.

The timing of surgery influences mortality and morbidity in adults with severe complicated infective endocarditis: a propensity analysis

AIMS To determine whether the timing of surgery could influence mortality and morbidity in adults with complicated infective endocarditis (IE). METHODS AND RESULTS In 291 consecutive adults with definite IE who underwent surgery during the active phase, we compared those operated on within the first week of antimicrobial therapy (n=95) to those operated on later (n=191). The impact of the timing of surgery on 6-month mortality, relapses, and postoperative valvular dysfunctions (PVD) was analysed using propensity score (PS) analyses. After stratification of the cohort into quintiles based on the PS, ≤1st week surgery was associated with a trend of decrease in 6-month mortality in the quintile of patients with the most likelihood of undergoing this early surgical management [quintile 5: 11% vs. 33%, odds ratio (OR)=0.18, 95% CI (confidence interval) 0.04-0.83, P=0.03]. Patients of this subgroup were younger, were more likely to have Staphylococcus aureus infections, congestive heart failure, and larger vegetations. Besides, ≤1st week surgery was associated with an increased number of relapses or PVD (16% vs. 4%, adjusted OR=2.9, 95% CI 0.99-8.40, P=0.05). CONCLUSION Surgery performed very early may improve survival in patients with the most severe complicated IE. However, a greater risk of relapses and PVD should be expected when surgery is performed very early.

Left Atrial Size is a Potent Predictor of Mortality in Mitral Regurgitation Due to Flail Leaflets: Results from a Large International Multicenter Study

Background— Left atrium (LA) enlargement is common in organic mitral regurgitation (MR) and is an emerging prognostic indicator. However, outcome implications of LA enlargement have not been analyzed in the context of routine clinical practice and in a multicenter study. Methods and Results— The Mitral Regurgitation International DAtabase (MIDA) registry enrolls patients with organic MR due to flail leaflets, diagnosed in routine clinical practice, in 5 US and European centers. We investigated the relation between LA diameter and mortality under medical treatment and after mitral surgery in 788 patients in sinus rhythm (64±12 years; median LA, 48 [43 to 52] mm). LA diameter was independently associated with survival after diagnosis (hazard ratio, 1.08 [1.04 to 1.12] per 1 mm increment). Compared with patients with LA <55 mm, those with LA ≥55 mm had lower 8-year overall survival (P<0.001). LA ≥55 mm independently predicted overall mortality (hazard ratio, 3.67 [1.95 to 6.88]) and cardiac mortality (hazard ratio, 3.74 [1.72 to 8.13]) under medical treatment. The association of LA ≥55 mm and mortality was consistent in subgroups. Similar excess mortality associated with LA ≥55 mm was observed in asymptomatic and symptomatic patients (P for interaction, 0.77). In patients who underwent mitral surgery, LA ≥55 mm had no impact on postoperative outcome (P>0.20). Mitral surgery was associated with greater survival benefit in patients with LA ≥55 mm compared with LA <55 mm (P for interaction, 0.008). Conclusions— In MR caused by flail leaflets, LA diameter ≥55 mm is associated with increased mortality under medical treatment, independent of the presence of symptoms or left ventricular dysfunction.

Outcome after surgical treatment performed within the first week of antimicrobial therapy during infective endocarditis: a prospective study.

BACKGROUND An increasing number of patients with infective endocarditis (IE) are operated on before the end of the first week of antimicrobial therapy. The mortality and morbidity of this specific group are unknown. AIMS To evaluate the outcome of patients with IE requiring cardiac surgery performed within the first week of antimicrobial therapy. METHODS All consecutive patients with a definite diagnosis of IE operated on within the first week of antimicrobial therapy were followed prospectively. Endpoints were in-hospital mortality and a combined endpoint of long-term cardiovascular death, recurrence and non-infective postoperative valvular dysfunction (PVD). The three main conditions requiring surgery, namely haemodynamic impairment, high embolic risk and periannular extension, were tested as potential predictors of outcome after adjustment for relevant variables. RESULTS Among the 95 patients included, surgery was performed a median time of 3 days after starting antimicrobial therapy. In-hospital mortality was 15%. The 3-year cumulative rates of the combined endpoint and of cardiovascular death were 38+/-7% and 27+/-7%, respectively. Recurrence occurred in 12% and PVD in 7%. Periannular extension was the main predictor of in-hospital death and the combined endpoint. CONCLUSION Despite the short time between starting antimicrobial therapy and performing surgery, the risk of death, recurrence and PVD does not appear excessively high. In the presence of periannular extension, however, surgery is associated with a greater risk of postoperative events.

Massive Biventricular Thrombosis as a Consequence of Myocarditis Findings From 2-Dimensional and Real-Time 3-Dimensional Echocardiography

A43-year-old man with medical history of gastroenteritis 2 weeks previously was referred to our intensive care unit for acute chest pain. At admission, the ECG showed negative T waves in V1, V2, V3, and V4 leads, and his troponin serum level was 0.6 ng/mL. His C-reactive protein level was elevated at 70 mg/L, and the serum blood count showed hyperleukocytosis with hyperlymphocytosis and thrombocytosis. Two-dimensional transthoracic echocardiogram revealed a dilated and hypokinetic left ventricle (LV) and a biventricular thrombosis (Figure 1). A dramatic and mobile apical thrombus appeared in the LV cavity; a smaller one near to the septo-basal wall was better assessed by real-time, 3-dimensional transthoracic echocardiogram (Figure 2, Movie I, and Movie II). Another thrombus was observed in the apex of the right ventricle (Figure 2, Movie III). Abdominal computed tomography scan revealed a massive splenic infarction that explained the thrombocytosis. The coronary angiogram was normal. Facing a large and mobile LV apical thrombus and a high risk of new embolization, we performed a total thrombectomy in an urgent setting through an aortotomy and both a left and right atriotomy. Despite an early postoperative recurrence of a small LV thrombus, the outcome was favorable, with disappearance of this thrombus after anticoagulation therapy, spontaneous resolution of the inflammatory syndrome, and an improvement in LV function. The presumptive final diagnosis was myocarditis complicated by biventricular thrombosis.A 43-year-old man with medical history of gastroenteritis 2 weeks previously was referred to our intensive care unit for acute chest pain. At admission, the ECG showed negative T waves in V1, V2, V3, and V4 leads, and his troponin serum level was 0.6 ng/mL. His C-reactive protein level was elevated at 70 mg/L, and the serum blood count showed hyperleukocytosis with hyperlymphocytosis and thrombocytosis. Two-dimensional transthoracic echocardiogram revealed a dilated and …

Eclipsed Mitral Regurgitation: A New Form of Functional Mitral Regurgitation for an Unusual Cause of Heart Failure with Normal Ejection Fraction

Background: Transient functional mitral regurgitation (MR) has never been reported as a cause of heart failure (HF) with normal ejection fraction (EF) in the absence of epicardial coronary artery stenosis. Results: Performance of echocardiography in patients with acute HF before initiation of HF medical treatment allowed identification of three patients with normal EF but transient massive functional MR during the HF episode. In all patients, massive MR occurred as a consequence of sudden extreme apical tenting of both leaflets with total lack of coaptation, despite normal EF and absence of detectable left ventricular (LV) remodeling, and despite absence of significant stenosis on coronary arteries. In all patients MR was triggered by methylergonovine injection and was reversible either spontaneously or after nitroglycerine administration, leaving patients with normal echocardiogram between HF episodes. In two patients, long-term administration of calcium channel blockers prevented recurrences of MR and HF, whereas in one, mitral valve was eventually replaced. Conclusion: Sudden reversible apical tenting of mitral leaflets with subsequent torrential MR and acute HF can occur despite normal EF, absence of pre-existing LV remodeling and absence of coronary artery stenosis. This atypical type of functional MR is an unusual mechanism of HF in patients with normal LVEF.

Pacemaker Lead Vegetation Trapped in Patent Foramen Ovale A Cause of Hypoxemia After Percutaneous Extraction

A 71-year-old man was admitted to our department with suspected pacemaker endocarditis because of unexplained fever and Staphylococcus epidermidis bacteremia. The patient’s history revealed a double-chamber pacemaker implantation 7 years ago for third-degree atrioventricular block. Transesophageal echocardiography showed a significant thickening of both leads associated with a mobile 2.7-cm vegetation on the ventricular lead. A patent foramen ovale was also noted on transesophageal echocardiography (Figure 1; supplemental Movie I). The diagnosis of endocarditis was thus confirmed, and percutaneous lead extraction was planned under antibiotic therapy with prior epicardial implantation. The extraction procedure was performed by lead traction associated with a laser sheath for both the auricular and ventricular leads. The immediate …A 71-year-old man was admitted to our department with suspected pacemaker endocarditis because of unexplained fever and Staphylococcus epidermidis bacteremia. The patient’s history revealed a double-chamber pacemaker implantation 7 years ago for third-degree atrioventricular block. Transesophageal echocardiography showed a significant thickening of both leads associated with a mobile 2.7-cm vegetation on the ventricular lead. A patent foramen ovale was also noted on transesophageal echocardiography (Figure 1; supplemental Movie I). The diagnosis of endocarditis was thus confirmed, and percutaneous lead extraction was planned under antibiotic therapy with prior epicardial implantation. The extraction procedure was performed by lead traction associated with a laser sheath for both the auricular and ventricular leads. The immediate …

Massive Biventricular Thrombosis as a Consequence of Myocarditis

A43-year-old man with medical history of gastroenteritis 2 weeks previously was referred to our intensive care unit for acute chest pain. At admission, the ECG showed negative T waves in V1, V2, V3, and V4 leads, and his troponin serum level was 0.6 ng/mL. His C-reactive protein level was elevated at 70 mg/L, and the serum blood count showed hyperleukocytosis with hyperlymphocytosis and thrombocytosis. Two-dimensional transthoracic echocardiogram revealed a dilated and hypokinetic left ventricle (LV) and a biventricular thrombosis (Figure 1). A dramatic and mobile apical thrombus appeared in the LV cavity; a smaller one near to the septo-basal wall was better assessed by real-time, 3-dimensional transthoracic echocardiogram (Figure 2, Movie I, and Movie II). Another thrombus was observed in the apex of the right ventricle (Figure 2, Movie III). Abdominal computed tomography scan revealed a massive splenic infarction that explained the thrombocytosis. The coronary angiogram was normal. Facing a large and mobile LV apical thrombus and a high risk of new embolization, we performed a total thrombectomy in an urgent setting through an aortotomy and both a left and right atriotomy. Despite an early postoperative recurrence of a small LV thrombus, the outcome was favorable, with disappearance of this thrombus after anticoagulation therapy, spontaneous resolution of the inflammatory syndrome, and an improvement in LV function. The presumptive final diagnosis was myocarditis complicated by biventricular thrombosis.A 43-year-old man with medical history of gastroenteritis 2 weeks previously was referred to our intensive care unit for acute chest pain. At admission, the ECG showed negative T waves in V1, V2, V3, and V4 leads, and his troponin serum level was 0.6 ng/mL. His C-reactive protein level was elevated at 70 mg/L, and the serum blood count showed hyperleukocytosis with hyperlymphocytosis and thrombocytosis. Two-dimensional transthoracic echocardiogram revealed a dilated and …

Pacemaker Lead Vegetation Trapped in Patent Foramen Ovale

A 71-year-old man was admitted to our department with suspected pacemaker endocarditis because of unexplained fever and Staphylococcus epidermidis bacteremia. The patient’s history revealed a double-chamber pacemaker implantation 7 years ago for third-degree atrioventricular block. Transesophageal echocardiography showed a significant thickening of both leads associated with a mobile 2.7-cm vegetation on the ventricular lead. A patent foramen ovale was also noted on transesophageal echocardiography (Figure 1; supplemental Movie I). The diagnosis of endocarditis was thus confirmed, and percutaneous lead extraction was planned under antibiotic therapy with prior epicardial implantation. The extraction procedure was performed by lead traction associated with a laser sheath for both the auricular and ventricular leads. The immediate …A 71-year-old man was admitted to our department with suspected pacemaker endocarditis because of unexplained fever and Staphylococcus epidermidis bacteremia. The patient’s history revealed a double-chamber pacemaker implantation 7 years ago for third-degree atrioventricular block. Transesophageal echocardiography showed a significant thickening of both leads associated with a mobile 2.7-cm vegetation on the ventricular lead. A patent foramen ovale was also noted on transesophageal echocardiography (Figure 1; supplemental Movie I). The diagnosis of endocarditis was thus confirmed, and percutaneous lead extraction was planned under antibiotic therapy with prior epicardial implantation. The extraction procedure was performed by lead traction associated with a laser sheath for both the auricular and ventricular leads. The immediate …