Mélanie Côté

Cerebral Embolism Following Transcatheter Aortic Valve Implantation : Comparison of Transfemoral and Transapical Approaches

OBJECTIVES The objective of this study was to compare the incidence of cerebral embolism (CE) as evaluated by diffusion-weighted magnetic resonance imaging (DW-MRI) following transapical (TA) transcatheter aortic valve implantation (TAVI) versus transfemoral (TF) TAVI. BACKGROUND The TA-TAVI approach avoids both the manipulation of large catheters in the aortic arch/ascending aorta and the retrograde crossing of the aortic valve, and this avoidance might lead to a lower rate of CE. METHODS This was a prospective multicenter study including 60 patients who underwent cerebral DW-MRI the day before and within the 6 days following TAVI (TF approach: 29 patients; TA approach: 31 patients). Neurologic and cognitive function assessments were performed at DW-MRI time points. RESULTS The TAVI procedure was performed with the Edwards valve and was successful in all cases but one (98%). A total of 41 patients (68%) had 251 new cerebral ischemic lesions at the DW-MRI performed 4 ± 1 days after the procedure, 19 patients in the TF group (66%) and 22 patients in the TA group (71%; p = 0.78). Most patients (76%) with new ischemic lesions had multiple lesions (median number of lesions per patient: 3, range 1 to 31). There were no differences in lesion number and size between the TF and TA groups. No baseline or procedural factors were found to be predictors of new ischemic lesions. The occurrence of CE was not associated with a measurable impairment in cognitive function, but 2 patients (3.3%) had a clinically apparent stroke within the 24 h following the procedure (1 patient in each group). CONCLUSIONS TAVI is associated with a high rate of silent cerebral ischemic lesions as evaluated by DW-MRI, with no differences between the TF and TA approaches. These results provide important novel insight into the mechanisms of CE associated with TAVI and support the need for further research to both reduce the incidence of CE during these procedures and better determine their clinical relevance.

Incidence, predictive factors, and prognostic value of new-onset atrial fibrillation following transcatheter aortic valve implantation.

OBJECTIVES This study sought to evaluate the incidence, predictive factors, and prognostic value of new-onset atrial fibrillation (NOAF) following transcatheter aortic valve implantation (TAVI). BACKGROUND Very few data exist on the occurrence of NOAF following TAVI. METHODS A total of 138 consecutive patients with no prior history of atrial fibrillation (AF) underwent TAVI with a balloon-expandable valve. Patients were on continuous electrocardiogram monitoring until hospital discharge, and NOAF was defined as any episode of AF lasting >30 s. All clinical, echocardiographic, procedural, and follow-up data were prospectively collected. RESULTS NOAF occurred in 44 patients (31.9%) at a median time of 48 h (interquartile range: 0 to 72 h) following TAVI. The predictive factors of NOAF were left atrial (LA) size (odds ratio [OR]: 1.21 for each increase in 1 mm/m(2), 95% confidence interval [CI]: 1.09 to 1.34, p < 0.0001) and transapical approach (OR: 4.08, 95% CI: 1.35 to 12.31, p = 0.019). At 30-day follow-up, NOAF was associated with a higher rate of stroke/systemic embolism (13.6% vs. 3.2%, p = 0.021, p = 0.047 after adjustment for baseline differences between groups), with no differences in mortality rate between groups (NOAF: 9.1%, no-NOAF: 6.4%, p = 0.57). At a median follow-up of 12 months (interquartile range: 5 to 20 months), a total of 27 patients (19.6%) had died, with no differences between the NOAF (15.9%) and no-NOAF (21.3%) groups, p = 0.58. The cumulative rate of stroke and stroke/systemic embolism at follow-up were 13.6% and 15.9%, respectively, in the NOAF group versus 3.2% in the no-NOAF group (p = 0.039, adjusted p = 0.037 for stroke; p = 0.020, adjusted p = 0.023 for stroke/systemic embolism). CONCLUSIONS NOAF occurred in about one-third of the patients with no prior history of AF undergoing TAVI and its incidence was increased in patients with larger LA size and those undergoing transapical TAVI. NOAF was associated with a higher rate of stroke/systemic embolism, but not a higher mortality, at 30 days and at 1-year follow-up.

Predictive factors and long-term clinical consequences of persistent left bundle branch block following transcatheter aortic valve implantation with a balloon-expandable valve

OBJECTIVES This study evaluated the predictive factors and prognostic value of new-onset persistent left bundle branch block (LBBB) in patients undergoing transcatheter aortic valve implantation (TAVI) with a balloon-expandable valve. BACKGROUND The predictors of persistent (vs. transient or absent) LBBB after TAVI with a balloon-expandable valve and its clinical consequences are unknown. METHODS A total of 202 consecutive patients with no baseline ventricular conduction disturbances or previous permanent pacemaker implantation (PPI) who underwent TAVI with a balloon-expandable valve were included. Patients were on continuous electrocardiographic (ECG) monitoring during hospitalization and 12-lead ECG was performed daily until hospital discharge. No patient was lost at a median follow-up of 12 (range: 6 to 24) months, and ECG tracing was available in 97% of patients. The criteria for PPI were limited to the occurrence of high-degree atrioventricular block (AVB) or severe symptomatic bradycardia. RESULTS New-onset LBBB was observed in 61 patients (30.2%) after TAVI, and had resolved in 37.7% and 57.3% at hospital discharge and 6- to 12-month follow-up, respectively. Baseline QRS duration (p = 0.037) and ventricular depth of the prosthesis (p = 0.017) were independent predictors of persistent LBBB. Persistent LBBB at hospital discharge was associated with a decrease in left ventricular ejection fraction (p = 0.001) and poorer functional status (p = 0.034) at 1-year follow-up. Patients with persistent LBBB and no PPI at hospital discharge had a higher incidence of syncope (16.0% vs. 0.7%; p = 0.001) and complete AVB requiring PPI (20.0% vs. 0.7%; p < 0.001), but not of global mortality or cardiac mortality during the follow-up period (all, p > 0.20). New-onset LBBB was the only factor associated with PPI following TAVI (p < 0.001). CONCLUSIONS Up to 30% of patients with no prior conduction disturbances developed new LBBB following TAVI with a balloon-expandable valve, although it was transient in more than one third. Longer baseline QRS duration and a more ventricular positioning of the prosthesis were associated with a higher rate of persistent LBBB, which in turn determined higher risks for complete AVB and PPI, but not mortality, at 1-year follow-up.

Predictive factors, efficacy, and safety of balloon post-dilation after transcatheter aortic valve implantation with a balloon-expandable valve

OBJECTIVES This study sought to evaluate the predictive factors, effects, and safety of balloon post-dilation (BPD) for the treatment of significant paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI). BACKGROUND Very few data exist on BPD after TAVI with a balloon-expandable valve. METHODS A total of 211 patients who underwent TAVI with a balloon-expandable valve were included. BPD was performed after TAVI if paravalvular AR ≥ 2 was identified by transesophageal echocardiography. Clinical events and echocardiographic data were prospectively recorded, and median follow-up was 12 (6 to 24) months. RESULTS BPD was performed in 59 patients (28%), leading to a reduction in at least 1 degree of AR in 71% of patients, with residual AR <2 in 54% of the patients. The predictors of the need for BPD were the degree of valve calcification and transfemoral approach, with valve calcification volume >2,200 and >3,800 mm(3) best determining the need for and a poor response to BPD, respectively. Patients who underwent BPD had a higher incidence of cerebrovascular events at 30 days (11.9% vs. 2.0%, p = 0.006), with most (83%) events within the 24 h after the procedure occurring in patients who had BPD. No significant changes in valve area or AR degree were observed at follow-up in BPD and no-BPD groups. CONCLUSIONS BPD was needed in about one-fourth of the patients undergoing TAVI with a balloon-expandable valve and was successful in about one-half of them. A higher degree of valve calcification and transfemoral approach predicted the need for BPD. BPD was not associated with any deleterious effect on valve function at mid-term follow-up, but a higher rate of cerebrovascular events was observed in patients who had BPD.

Electrocardiographic changes and clinical outcomes after transapical aortic valve implantation

BACKGROUND Transapical aortic valve implantation (TAVI) for the treatment of severe aortic stenosis requires the insertion of a large catheter through the left ventricular apex. However, the electrocardiographic (ECG) changes associated with the incision and repair of the left ventricular apex and the potential damage to the conduction system caused by implanting a balloon-expandable valve in aortic position are not known. The objective of our study was to determine the incidence, type, and timing of ECG changes associated with TAVI. METHODS The standard 12-lead ECGs of 33 consecutive patients (mean age 81 +/- 9 years, 13 men) diagnosed with symptomatic severe aortic stenosis (valve area 0.62 +/- 0.16 cm(2)) who underwent TAVI with an Edwards-SAPIEN valve were analyzed at baseline (within 24 hours before the procedure), immediately (within 6 hours) after the procedure, at hospital discharge, and at 1-month follow-up. RESULTS There were no procedural deaths, and 30-day mortality was 6%. The incidence of complete left ventricular branch block (LBBB) and left anterior hemiblock (LAHB) increased from 9% and 3% at baseline to 27% and 36% after the procedure, respectively (P < .03 for both). A lower (ventricular) position of the valve relative to the hinge point of the anterior mitral leaflet was associated with a higher incidence of new LBBB (35% vs 0%, P = .029); and a greater valve size-aortic annulus ratio, with the occurrence of new LAHB (1.20 +/- 0.07 vs 1.14 +/- 0.06, P = .021). At 1-month follow-up, the rate of LBBB and LAHB decreased to 13% and 10%, respectively (P = not significant compared with baseline). There were no cases of new atrioventricular block, and no patient needed pacemaker implantation. Transient (<48 hours) ST-elevation changes, mostly in the anterior and/or lateral leads, occurred in 6 patients (18%) immediately after the procedure; but only 1 of these patients presented new Q waves at 1-month follow-up. CONCLUSIONS Transapical aortic valve implantation was associated with a significant but transient (<1 month) increase in LBBB and LAHB, with no patient requiring pacemaker implantation. These changes were partially related to both lower (more ventricular) valve positioning and greater valve oversizing. Transient (<48 hours) ST-segment elevation changes occurred in about one fifth of the patients after the procedure, but only a minority developed new Q waves in the ECG.

Sex differences in inflammatory markers: what is the contribution of visceral adiposity?

BACKGROUND C-reactive protein (CRP) concentrations have been found to be higher in premenopausal women than in men, whereas interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) concentrations have been reported to be lower in women than in men. OBJECTIVE The objective was to determine whether the sex difference in body fat distribution accounts for the observed sex differences in inflammatory markers. DESIGN Plasma CRP, IL-6, and TNF-alpha concentrations were measured in 208 healthy men (age: 42.2 +/- 15.2 y) and in 145 healthy women (age: 36.8 +/- 11.1 y). RESULTS Compared with men, premenopausal women had higher CRP concentrations [1.24 (25th percentile: 0.54; 75th percentile: 3.04) compared with 0.94 (0.51, 2.40) mg/L; P < 0.05] and lower plasma TNF-alpha concentrations [1.50 (25th percentile: 1.23; 75th percentile: 1.82) compared with 1.71 (1.40, 2.05) pg/mL; P < 0.001]. No sex difference in IL-6 concentrations was noted. Regression analyses indicated that the relation between CRP or IL-6 and visceral adipose tissue (VAT) and subcutaneous AT (SAT) was sex-specific; a significantly steeper slope was observed in women than in men (P < 0.05). Sex differences in CRP concentrations were abolished after SAT was adjusted for. In a multivariate model of the whole sample, we found that both SAT and VAT and the sex x SAT interaction term were significant correlates of CRP and IL-6 concentrations. Finally, whereas CRP concentrations were largely influenced by visceral adiposity in men, subcutaneous adiposity was the key correlate of CRP in women. CONCLUSION The higher CRP concentrations found in women appear to be due to their greater accumulation of subcutaneous fat than that observed in men.

Coronary obstruction following transcatheter aortic valve implantation: a systematic review.

OBJECTIVES This study sought to evaluate, through a systematic review of the published data, the main baseline characteristics, management, and clinical outcomes of patients suffering coronary obstruction as a complication of transcatheter aortic valve implantation (TAVI). BACKGROUND Very few data exist on coronary obstruction after TAVI. METHODS Studies published between 2002 and 2012, with regard to coronary obstruction as a complication of TAVI, were identified with a systematic electronic search. Only the studies reporting data on the main baseline and procedural characteristics, management of the complication, and clinical outcomes were analyzed. RESULTS A total of 18 publications describing 24 patients were identified. Most (83%) patients were women, with a mean age of 83 ± 7 years and a mean logistic European System for Cardiac Operative Risk Evaluation score of 25.1 ± 12.0%. Mean left coronary artery (LCA) ostium height and aortic root width were 10.3 ± 1.6 mm and 27.8 ± 2.8 mm, respectively. Most patients (88%) had received a balloon-expandable valve, and coronary obstruction occurred more frequently in the LCA (88%). Percutaneous coronary intervention was attempted in 23 cases (95.8%) and was successful in all but 2 patients (91.3%). At 30-day follow-up, there were no cases of stent thrombosis or repeat revascularization, and the mortality rate was 8.3%. CONCLUSIONS Reported cases of coronary obstruction after TAVI occurred more frequently in women, in patients receiving a balloon-expandable valve, and the LCA was the most commonly involved artery. Percutaneous coronary intervention was a feasible and successful treatment in most cases. Continuous efforts should be made to identify the factors associated with this life-threatening complication to implement the appropriate measures for its prevention.

Effect of exercise training on cardiometabolic risk markers among sedentary, but metabolically healthy overweight or obese post-menopausal women with elevated blood pressure.

OBJECTIVE To investigate the effect of exercise training on markers of the lipoprotein-lipid profile and inflammatory markers in post-menopausal overweight/obese women with a moderately elevated systolic blood pressure. METHODS A total of 267 women [mean body mass index (BMI)=32.0+/-5.7kg/m(2) and mean age=57.3+/-6.6 years] underwent a 6-month exercise intervention program. Exercise training was performed 3-4 times per week at a targeted heart rate corresponding to 50% of the maximal oxygen consumption. RESULTS Compared to baseline values, mean change in relative VO(2) max (the primary endpoint) was of 1.18+/-2.25mL/minkg (p<0.0001), mean weight loss was of 1.4+/-3.3kg (p<0.0001), mean reduction in waist circumference was of 2.4+/-6.9cm (p<0.0001) and systolic blood pressure did not change significantly (-1.2+/-13.0mmHg, NS). No changes were observed in markers of the lipoprotein-lipid profile. No changes were observed for plasma levels of C-reactive protein, interleukin-6, tumor-necrosis factor-alpha and adiponectin. Changes in VO(2) max were negatively associated with changes in body weight (r=-0.26, p<0.0001) and waist circumference (r=-0.16, p=0.01), but not with changes in cardiometabolic risk markers. CONCLUSION Although exercise training significantly increased cardiorespiratory fitness in these sedentary, but metabolically healthy obese/overweight women with a moderately elevated systolic blood pressure, no significant improvements were observed in their cardiometabolic risk profile.

Inflammatory biomarkers, physical activity, waist circumference, and risk of future coronary heart disease in healthy men and women

AIMS The aim of this study was to determine the contribution of physical activity and abdominal obesity to the variation in inflammatory biomarkers and incident coronary heart disease (CHD) in a European population. METHODS AND RESULTS In a prospective case-control study nested in the European Prospective Investigation into Cancer and Nutrition-Norfolk cohort, we examined the associations between circulating levels or activity of C-reactive protein, myeloperoxidase (MPO), secretory phospholipase A2 (sPLA2), lipoprotein-associated phospholipase A2 (Lp-PLA2), fibrinogen, adiponectin, waist circumference, physical activity, and CHD risk over a 10-year period among healthy men and women (45-79 years of age). A total of 1002 cases who developed fatal or non-fatal CHD were matched to 1859 controls on the basis of age, sex, and enrolment period. Circulating levels of C-reactive protein, sPLA2 (women only), fibrinogen, and adiponectin were linearly associated with increasing waist circumference and decreasing physical activity levels. After adjusting for waist circumference, physical activity, smoking, diabetes, systolic blood pressure, low-density lipoprotein and high-density lipoprotein cholesterol levels, and further adjusted for hormone replacement therapy in women, C-reactive protein, MPO (men only), sPLA2, fibrinogen, but not Lp-PLA2 and adiponectin were associated with an increased CHD risk. CONCLUSION Inactive participants with an elevated waist circumference were characterized by deteriorated levels of inflammatory markers. However, several inflammatory markers were associated with an increased CHD risk, independent of underlying CHD risk factors such as waist circumference and physical activity levels.

Abdominal obesity: The cholesterol of the 21st century?

Cardiovascular disease (CVD) is a leading cause of morbidity and death in many countries worldwide. With the help of epidemiological, metabolic and clinical studies conducted over the past decades, the key factors contributing to the development of CVD have been identified. In this regard, several modifiable (hypertension, smoking, elevated cholesterol or low-density lipoprotein-cholesterol concentrations, reduced levels of high-density lipoprotein-cholesterol, type 2 diabetes) and nonmodifiable (age, sex, genetic predisposition) CVD risk factors have been recognized. Although better acute care and chronic pharmacological management have contributed to reduce CVD mortality, CVD morbidity remains very high. It has been proposed that this situation could be the consequence of the evolving landscape of CVD risk factors, which include, among others, poor nutritional habits and a reduction in physical activity contributing to the epidemic of obesity sweeping the world. However, obesity is heterogeneous both in terms of its etiology and its metabolic complications. Body fat distribution, especially visceral adipose tissue accumulation, has been found to be a major correlate of a cluster of diabetogenic and atherogenic abnormalities that has been described as the metabolic syndrome. The importance of abdominal obesity in association with the development of CVD and type 2 diabetes has been recognized in several studies, beyond the contribution of overall obesity. Additional evidence also suggests that the CVD risk related to the hyperglycemic state observed in subjects with the metabolic syndrome or type 2 diabetes is largely explained by the high prevalence of the metabolic complications of abdominal obesity. Although the presence of the metabolic syndrome clearly increases CVD risk, its clinical diagnosis is not sufficient to classify a patient at high risk for a cardiovascular event because attention must also be paid to the presence of traditional risk factors in the calculation of global CVD risk. The additional information provided by the metabolic syndrome to the risk attributed to traditional risk factors in the calculation of global CVD risk has been defined as global cardiometabolic risk. The fight against abdominal obesity as a major cause of CVD morbidity and mortality will require major societal changes and the involvement of dieticians, kinesiologists and behaviour modification specialists in clinical practice to reshape our physical activity and dietary habits. Finally, the early prevention of overweight/obesity/abdominal obesity in children, starting as early as conception, and the identification of key drivers of unhealthy nutritional and sedentary behaviours are the cornerstone of a successful comprehensive plan to fight CVD morbidity.