Marcel Laurent

Valve replacement in patients with critical aortic stenosis and depressed left ventricular function: predictors of operative risk, left ventricular function recovery, and long term outcome

Objectives: To identify predictors of operative and postoperative mortality and of functional reversibility after aortic valve replacement (AVR) in patients with aortic stenosis (AS) and severe left ventricular (LV) systolic dysfunction. Methods and results: Between 1990 and 2000, 155 consecutive patients (mean (SD) age 72 (9) years) in New York Heart Association (NYHA) heart failure functional class III or IV (n  =  138) and with LV ejection fraction (LVEF) ⩽ 30% underwent AVR for critical AS (mean (SD) valve area index 0.35 (0.09) cm2/m2). Thirty day mortality was 12%. NYHA class (3.7 (0.6) v 3.2 (0.7), p  =  0.004), cardiothoracic ratio (CTR) (0.63 (0.07) v 0.56 (0.06), p < 0.0001), pulmonary artery systolic pressure (63 (25) v 50 (19) mm Hg, p  =  0.03), and prevalence of complete left bundle branch block (22% v 8%, p  =  0.03) and of renal insufficiency (p  =  0.001) were significantly higher in 18 non-survivors than in 137 survivors. In multivariate analysis, the only independent predictor of operative mortality was a CTR ⩾ 0.6 (odds ratio (OR) 12.2, 95% confidence interval (CI) 5.4 to 27.4, p  =  0.002). The difference between preoperative and immediate postoperative LVEF (early-ΔEF) was > 10 ejection fraction units (EFU) in 55 survivors. In multivariate analysis, CTR (OR 5.95, 95% CI 3.0 to 11.6, p  =  0.006) and mean transaortic gradient (OR 1.05, 95% CI 1.0 to 1.1, p < 0.05) were independent predictors of an early-ΔEF > 10 EFU. During a mean (SD) follow up of 4.6 (3) years, 50 of 137 (36%) 30 day survivors died, 31 of non-cardiac causes. Diabetes (OR 3.8, 95% CI 2.4 to 6.0, p  =  0.003), age ⩾ 75 years (OR 2.6, 95% CI 2.1 to 4.5, p  =  0.004), and early-ΔEF ⩽ 10 EFU (OR 0.96, 95% CI 0.94 to 0.97, p  =  0.01) were independent predictors of long term mortality. Among 127 survivors, the percentage of patients in NYHA functional class III or IV decreased from 89% preoperatively to 3% at one year. The decrease in functional class was significantly greater in patients with an early-ΔEF > 10 EFU than patients with an early-ΔEF ⩽ 10 EFU (p  =  0.02). In addition, the mean (SD) LVEF at one year was 53 (11)% in patients with an early-ΔEF > 10 EFU and 42 (11)% in patients with early-ΔEF ⩽ 10 EFU (p < 0.001). Conclusions: Despite a relatively high operative mortality, AVR for AS and severely depressed LVEF was beneficial in the majority of patients. Early postoperative recovery of LV function was associated with significantly greater relief of symptoms and longer survival.

Characteristics and outcome in arrhythmogenic right ventricular dysplasia

Abstract Based on our findings, long-term prognosis of ARVD would appear to be more favorable than reported earlier. Wide use of β blockers may have had a beneficial effect on prognosis, suggesting that medical treatment is of major importance in reducing the risk of sudden death.

Argument for a Doppler echocardiography during exercise in assessing asymptomatic patients with severe aortic stenosis.

AIMS Exercise stress testing (EST) is recommended by guidelines to risk-stratify patients with asymptomatic valvular aortic stenosis (AS), though the role of quantitative exercise-Doppler echocardiography has rarely been studied. This prospective study sought to correlate standard EST results with the haemodynamic measurements made during exercise by Doppler echocardiography. METHODS AND RESULTS We performed rest and semi-supine exercise Doppler echocardiography in 44 consecutive patients (mean age=68+/-12 years) with aortic valve areas<or=0.6 cm2/m2. The effective aortic valve area (EOA), cardiac output (CO), maximal transvalvular velocity, and pulmonary pressure were monitored over the test. No serious adverse event was observed. EST was positive in 26 (Group 1) and negative in 18 (Group 2) patients. Baseline echocardiographic measurements were similar (EOA 0.77+/-0.15 vs. 0.78+/-0.14 cm2; CO 5.5+/-1.6 vs. 5.9+/-2 L/min) in both groups. Exercise-induced changes in CO (+2.9+/-2 vs. +4.3+/-1.8 L/min, P=0.04) and EOA (-0.04+/-0.18 vs. +0.15+/-0.24 cm2, P=0.015) were significantly greater in Group 2. A correlation between changes in EOA and changes in CO during exercise was observed, but significantly higher in Group 2 (P=0.04). CONCLUSION In the presence of severe asymptomatic AS, exercise Doppler echocardiography, assessing the mechanisms behind a positive EST, appears very promising but further studies with prognosis assessment remain necessary.

Simple bedside clinical evaluation versus established scores in the estimation of operative risk in valve replacement for severe aortic stenosis

BACKGROUND The operative risk of cardiac surgery is ascertained preoperatively on the basis of scores validated in multinational studies. However, the value they add to a simple bedside clinical evaluation (CE) remains controversial. AIMS To compare operative mortality (defined as death from all causes before the 31st postoperative day) predicted by CE with that predicted by additive and logistic EuroSCOREs, EuroSCORE II and Society of Thoracic Surgeons (STS), Ambler and age-creatinine-ejection fraction (ACEF) scores in patients undergoing aortic valve replacement (AVR) for severe aortic stenosis. METHODS Overall, 314 consecutive patients were included who underwent AVR between October 2009 and November 2011 (22% with coronary artery bypass graft); mean age 73.4 ± 9.7 years (29% aged>80 years). Based on CE, patients were divided into four predefined groups of increasing estimated mortality risk: I ≤ 3.9%; II 4-6.9%; III 7-9.9%; IV ≥ 10%. The positive and negative predictive values of the six scores and CE were compared. RESULTS The observed overall operative mortality was 5.7%. The distribution of the four predicted mortality groups by each score was highly variable. The positive predictive value, calculated for the 64 patients classified at highest risk by CE (groups III or IV) or each score, was 17.2% for EuroSCORE II, 14.1% for CE and STS scores, 10.9% for additive and logistic EuroSCOREs, 10.6% for ACEF and 10.2% for Ambler. The positive predictive value of each score in the low-risk groups (I and II) ranged from 2.8% to 4.4%. CONCLUSION A simple bedside CE appears as reliable as the various established scores for predicting operative risk in patients undergoing surgical aortic valve replacement. The development and validation of more comprehensive risk stratification tools, including risk factors thus far neglected, seems warranted.

Transpulmonary correction of an isolated aortopulmonary window in an adult.

We describe the operative management of a 65‐year‐old patient with a congenital type I aortopulmonary window. At surgery, heavy calcifications on the aortic side of the defect, and close proximity with the left coronary ostium, prevented patch repair from the transaortic access. Patch closure through a combined transpulmonary approach was therefore required. This case illustrates unique features of a late‐presenting aortopulmonary window. doi: 10.1111/jocs.12224 (J Card Surg 2013;28:663–665)

171: Risk scores versus pragmatic clinical assessment to predict operative risk in aortic valve replacement for aortic stenosis

Background Preoperative risk assessment of cardiac surgery is based on international validated scores. However their additional value above simple clinical assessment (CA) remains controversial. The aim of this study was to compare CA by cardiologists with the 5 most commonly used scores (additive and logistic EuroSCORE, EuroSCORE II, STS-score, Ambler-score) to predict perioperative mortality in patients undergoing aortic valve replacement for aortic stenosis. Methods From October 2009 to November 2011, 314 consecutive patients (73±9,7 years; 29% octogenarians) were included. A surgical coronary revascularization was associated to aortic valve replacement in 22%. According to the expected mortality by CA, patients were split in 4 groups: “low” mortality risk [0–3.9%], “intermediate” [4–6.9%], “high” [7–9.9%] and “very high” ≥10%. The 5 scores were calculated for all the patients. Results Observed total operative mortality was 5,7%. The distribution of predicted mortality in the 4 groups was highly different according to the method. The positive predictive value (PPV) of each method was calculated for the 21% most at risk patients (corresponding to the 64 patients ranked in “high” and “very high” mortality risk groups by CA) resulting in PPV=17.2% for EuroSCORE II, 14.1% for CA and STS-score, 10.9% for additive EuroSCORE and logistic EuroSCORE and 10% for Ambler score. Predictive values of “low” and “intermediate” mortality risks were not significantly different depending on the methods (PPV between 2.8 and 4.4%). Conclusion pragmatic CA remains useful to predict operative risk in patients with surgical aortic valve replacement and to balance the different international scores.

150: The incidence, risk factors and prognosis of acute kidney injury (AKI) according to the valve academic research consortium (VARC) definition after transcatheter aortic valve implantation (TAVI)

Background Few data are currently available about patients characteristics and procedural features associated with AKI after TAVI using the new recommended VARC definition. Methods 99 patients underwent TAVI (1 procedural death, 78.8% transfemoral, 12.1% trans-apical/aortic and 9.1% subclavian access) between February 2009 and September 2011 at Rennes university hospital. Creatinine level was assessed daily at least up to 72 hours after TAVI. Patients’ characteristics, procedural features and outcomes according to VARC definitions were studied to evaluate determinants and prognostic impact of AKI. Results AKI occurred in 22 patients (22.2%). Among them, 5 were AKI 2 (5.1%), 8 were AKI 3 (9.1%) including 4 who needed dialysis (4%). At baseline, compared to no AKI or AKI 1, AKI 2 or 3 patients had a higher prevalence of moderate or severe chronic kidney disease (p=0.046) and ≥ grade 2 mitral regurgitation (p=0.03). During the post TAVI hospitalization, AKI 2 or 3 was associated to a higher rate of death from any cause (p=0.0009), major bleeding, acute heart failure (both p=0.002), infectious complications (p=0.0008) and longer total and ICU hospitalization duration (p=0.0004 and Conclusion AKI 2 or 3 as defined by the VARC criteria were associated with a higher risk of post procedural death because of their association with other major post procedural complications. AKI 3 was associated with a higher risk of short term worse functional outcomes. Download : Download full-size image Figure 1: Time-to-event curv No AKI or AKI 1 N= 85 AKI 2 or 3 N=13 p value Age-yr 79.0 ±10.2 80.5±6.7 0.63 Logistic EuroSCORE 19.8±12.2 19.3±10.2 0.89 Left ventricular ejection fraction-% 48.2±14.4 58.1±12.5 0.02 Aortic valve area-cm2 0.68±0.15 0.71±0.22 0.56

Letter by Leurent et al Regarding Article, “Prevalence and Clinical Significance of Papillary Muscle Infarction Detected by Late Gadolinium-Enhanced Magnetic Resonance Imaging in Patients With ST-Segment Elevation Myocardial Infarction”

To the Editor: We first would like to thank Tanimoto et al1 for their study regarding cardiac magnetic resonance and ischemic mitral regurgitation (IMR). They sought to explore the relationship between papillary muscle infarction (detected by postgadolinium cardiac magnetic resonance) and IMR. IMR is still a subject of debate: …