Najime Bouhzam

Feasibility and safety of early discharge after transfemoral transcatheter aortic valve implantation with the Edwards SAPIEN-XT prosthesis.

There is currently no consensus on the duration of hospitalization required after transfemoral transcatheter aortic valve implantation (TAVI). We report the feasibility and safety of early discharge after TAVI with the Edwards SAPIEN-XT prosthesis. From 2009 to 2013, 337 patients underwent transfemoral TAVI with the Edwards SAPIEN-XT prosthesis using local anesthesia and were discharged home either early (≤3 days, Early Discharge group, n = 121) or after 3 days (Late Discharge group, n = 216). The primary end point of the study combined death and rehospitalization from discharge to 30-day follow-up. Patients in the Early Discharge group were less symptomatic (New York Heart Association class ≥III: 64.5% vs 75.5%, p = 0.01) and had less renal failure (creatinine: 102.1 ± 41.0 vs 113.3 ± 58.9 μmol/L, p = 0.04), atrial fibrillation (33.1% vs 46.3%, p = 0.02), and previous balloon aortic valvuloplasty (11.6% vs 23.1%, p = 0.01) and were more likely to have a pacemaker before TAVI (16.5% vs 8.3%, p = 0.02). Pre-existing pacemaker (p = 0.05) and the absence of acute kidney injury (p = 0.02) were independent predictors of an early discharge, whereas previous balloon aortic valvuloplasty (p = 0.03) and post-TAVI blood transfusions (p = 0.002) were independent predictors of late discharge. The primary end point occurred in 4 patients (3.3%) in the Early Discharge group and in 11 patients (5.1%) in the Late Discharge group (p = 0.58). In conclusion, the results of our study suggest that early discharge after transfemoral TAVI using the Edwards SAPIEN-XT prosthesis is feasible and safe in selected patients.

Multimodal imaging in the diagnosis of isolated left ventricular noncompaction.

Left ventricular noncompaction (LNVC), first described in 1984, is a rare congenital cardiomyopathy that is thought to be caused by arrest of normal embryogenesis of the endocardium and the myocardium, and characterized by multiple prominent trabeculations with deep intertrabecular recesses. LVNC can be associated with other congenital cardiac abnormalities such as atrial septal defect and ventricular septal defect, but it can occur in isolation. The clinical manifestations of the disease are variable, ranging from no symptoms to signs of heart failure, systemic emboli, and ventricular arrhythmias. The diagnosis is established by two dimensional echocardiography or magnetic resonance imaging. We report the case of a 44-year-old man with LVNC and discuss the role of multimodal imaging in the diagnosis and assessment of the disease.ZusammenfassungDie linksventrikuläre Noncompaction-Kardiomyopathie (LVNC) ist eine seltene kongenitale Erkrankung, die erstmals 1984 beschrieben wurde. Man nimmt an, dass ihr eine Unterbrechung der normalen Embryonalentwicklung des Endokards und Myokards zugrunde liegt. Charakteristisch sind multiple prominente Trabekel mit tiefen intertrabekulären Recessus. Die LVNC kann mit anderen kongenitalen Herzfehlern wie Vorhof- und Ventrikelseptumdefekten vergesellschaftet sein oder auch isoliert auftreten. Klinisch manifestiert sie sich uneinheitlich: Das Bild reicht von Symptomfreiheit bis zu Zeichen einer Herzinsuffizienz, systemischen Emboli und ventrikulären Herzrhythmusstörungen. Die Diagnose wird mithilfe der 2-dimensionalen Echokardiographie und Magnetresonanztomographie gestellt. In der vorliegenden Kasuistik berichten wir über einen 44-jährigen Patienten mit LVNC. Die Rolle, die die multimodale Bildgebung in der Diagnose und Beurteilung der Erkrankung spielt, wird erörtert.

0148: Characteristics and clinical outcome of patients admitted in the intensive care unit for acute myocarditis

Introduction Although myocarditis is increasingly recognized in clinical practice, the characteristics and prognosis of patients with suspected myocarditis are poorly defined. Therefore, the aim of this study was to describe the characteristics and clinical outcome of patients admitted to a university hospital for acute myocarditis. Methods Retrospective study of patients admitted to the cardiology intensive care unit of a university hospital between January 2009 and March 2014 with a discharge diagnosis of myocarditis. Patients with suspected acute coronary syndrome (ACS) underwent either coronary angiography or coronary computed tomography angiography (CCTA). Clinical follow-up was obtained by phone call to the referring physician. Results During the study period, 84 patients (mean age 37±14 years old, 83% males) were admitted for myocarditis. 54% of admissions occurred between November and February. A chest pain was present in 93% of Pts and 35.7% of Pts had fever in the preceding month. In 38.1% of Pts, ECG was suggestive of ACS whereas diffuse ST elevation was found in 26.2% of Pts and a normal ECG in 23.8%. A pericardial effusion was found in 31.3% of Pts. Mean ejection fraction was 59.6±8.8%. Peak Troponin was 657±704ng/l. CRP was increased in 75.3%. A cardiac MRI was performed in 90.5% of cases and a coronary angiography in 47.6% of cases. No endomyocardial biopsy was performed. An infectious aetiology was found in 47.6% of cases. Treatment included aspirin (87.5%), beta-blockers (66.5%), and ACE inhibitors (42.9%). There was no death during hospital stay. At a mean follow-up of 28±20 months, 2 Pts (2.6%) died from non-cardiac causes and recurrences occurred in only 5.3% of Pts. Mean ejection fraction was 62.1±5.3%. Conclusion Patients admitted in a cardiology intensive care unit for acute myocarditis are mostly young males and a large part of admissions occurs during winter. In-hospital and mid-term outcome is good.

0177: Feasibility and safety of early discharge after transfemoral transcatheter aortic valve implantation

There is currently no consensus on the duration of monitoring required after TAVI. Between october 2009 and november 2013, 371 consecutive patients underwent transfemoral TAVI in our institution, all performed using the Edwards SAPIEN-XT prosthesis and local anesthesia. All the patients were monitored in intensive care unit for at least 24 hours after TAVI. We excluded 12 Patients implanted with a Corevalve, 14 patients who died before discharge, and 8 patients who were not discharge d straight home. The remaining 337 patients were discharged at home, 121 (36%) within 3 days (early discharge group) and 216 (64%) more than 3 days after TAVI (conventional discharge group). The primary end point combined death and re-hospitalization at 30 days. All adverse events were adjudicated according to the Valve Academic Research Consortium-2. The incidence of early discharge rose from 0% in 2009 to 53.2% of cases in 2013. Before (plutot prior to?) TAVI, patients in the early discharge group were less symptomatic (NYHA >III: 64.5% vs. 75.5%, p=0.01) and had less renal failure (creatinine: 102.1±41.0 vs. 113.3±58.9µmol/l, p=0.04), less atrial fibrillation (33.1% vs. 46.3%, p=0.02), and less previous balloon aortic valvuloplasty (11.6% vs. 23.1%, p=0.01) than those in the conventional discharge group. In contrast, patients in the early discharge group were more likely to have a pacemaker before TAVI (16.5% vs. 8.3%, p=0.02). After multivariable analysis, pacemaker before TAVI (OR 0.44; 95% CI 0.19-0.99; p=0.05), previous balloon aortic valvuloplasty (OR 2.26; 95% CI 1.10-4.64; p=0.03), transfusions (OR 9.6; 95% CI 2.36-38.94; p=0.002), and delta creatinin (OR 0.99; 95% CI 0.98-0.99; p=0.02) were independent predictive factors of early discharge. The primary end-point occurred in 7 (5.8%) patients in the early discharge group and in 16 (7.1%) patients in the conventional discharge group without significant difference (p=0.60). No patients died in the early discharge group at 30-day follow-up. The results of our study suggest that early discharge is feasible and safe after TAVI using the Edwards-SAPIEN XT prosthesis in selected patients

0196: « Steb by step » expansion of Edwards SAPIEN XT prosthesis during transcatheter aortic valve implantation

Objectives To evaluate feasibility, safety and advantage of underexpansion of Edwards SAPIEN XT prosthesis during transcatheter aortic valve implantation (TAVI). Methods We retrospectively analyzed 157 transfemoral TAVI procedures performed between October 2012 and December 2013 in the University Hospital of Rouen. Thirty-six (22.9%) patients had intentional underexpansion of the EDWARDS SAPIEN XT prosthesis since more than 20% area oversizing was anticipated with Computed tomography (CT) assessment of aortic annulus. Underexpansion of Edwards SAPIEN XT prosthesis was performed by reducing the volume of fluid within the valve deployment balloon. The Primary endpoint was aortic regurgitation (AR) at the end of the procedure. Results Mean age was 83.4±5.8 years and the mean logistic EuroSCORE of 15.4±9.6%. The initial fluid volume used for valve deployment was 90.1±3.1% of the theorical total volume (TTV) without significant difference among the 3 sizes of prostheses (90.2±4.1%, 89.5±2.6%, and 84.8±3.2% for 23, 26, and 29-mm valves, respectively). AR immediately after the first inflation was grade ≤I in 20 (55.6%) pts, grade II in 9 (25%) pts, and grade III in 7 (19.4%) pts. Stent diameter measured immediately after first inflation represented 94.2±4.1% of the prosthesis theorical diameter. Post-dilatation was deemed necessary in 14 cases (39.4%). At the end of the procedure, AR was Conclusion Our study suggest that underexpansion of Edwards SAPIEN-XT prosthesis is feasible during transfemoral TAVI procedures when more than 20% area oversizing is anticipated by CT. However, post-dilatation is mandatory in about 40% of cases to reduce significant residual aortic regurgitation but can be complicated by aortic annulus rupture

0179: Assessment of paravalvular aortic regurgitation after transcatheter aortic valve implantation using cardiac magnetic resonance imaging: a comparative study with echocardiography and angiography

Assessment of paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) using Edwards SAPIEN XT valve remains challenging using transthoracic echocardiography (TTE) or angiography. Cardiac magnetic resonance imaging (c-MRI) has a low intraobserver and interobserver variability in the assessment of regurgitant volumes and might be more reliable to assess AR post-TAVI. We therefore aimed to evaluate the value of c-MRI to assess paravalvular AR after TAVI. Between February 2012 and March 2013, 132 consecutive patients underwent successful TAVI using exclusively Edwards SAPIEN XT prosthesis. AR was evaluated by c-MRI, TTE and angiography in 45 patients (27 women, mean age 84.1±7.1 years). Angiography was performed immediately after TAVI whereas TTE and c-MRI were performed one month after implantation. At baseline c-MRI, the mean aortic regurgitant fraction (ARF) was 21.3±12.5%. A significant AR (> grade II) was present in 24 (56%) patients using c-MRI (30 50 Y%) whereas it was only observed in 18 (40%) and 12 (27%) patients using TTE and angiography, respectively. Interestingly, there was a poor correlation between c-MRI and TTE (r=0.16, p=0.28) and between c-MRI and angiography (r=0.30, p=0.06). In contrast, there was a good correlation between TTE and angiography (r=0.6, p

0219 : Outcomes of patients undergoing femoral covered stent graft during percutaneous transcatheter aortic valve implantation

Although vascular complications are frequent after percutaneous transcatheter aortic valve implantation (TAVI), they can be managed percutaneously most of the time by implanting a covered stent graft in the femoral artery. Aims To evaluate the characteristics of patients who required femoral stent implantation after TAVI and to determine the long-term impact of stent placement in the femoral position. Methods Between January 2011 and December 2013, 320 patients underwent transfemoral TAVI in our center using the Edwards Sapien XT valve. After gaining vascular access, a pre-closure technique was performed with a 10-F ProStar XL closure device followed by16 to 20-F sheath insertion for 23, 26 or 29mm valve implantation. After valve implantation and sheath removal, access site was closed with the ProStar device. An ilio-femoral angiography was performed via the contralateral femoral artery to assess final result and a self-expandable covered stent graft was placed at the level of vessel injury in case of persistent bleeding despite prolonged manual compression or balloon occlusion. Follow-up was performed by phone call and duplex ultrasonography of the access site. Results 29 (9%) patients required emergency femoral covered stent graft implantation. Patients characteristics were comparable to those of patients who did not require stent implantation except for previous anticoagulant therapy which was significantly associated with stent implantation (44.8% vs 27.1%, p = 0.045). Despite stent implantation, 2 patients underwent surgery for persistent bleeding. Stent implantation did not affect survival (p=0.456). At a median follow-up of 23 months, only 1 patient complained of groin discomfort impacting his daily life. Neither stent fracture nor occlusion was noted by ultrasonography. Conclusion Vascular complications after TAVI can be safely treated percutaneously by femoral covered stent graft with minimal long-term functional impairment and no impact on survival.

Heart failure as herald.

Heart Failure as Herald Najime Bouhzam, MD, Lamyaa Nkhali, MD, Bogdan Borz, MD, Matthieu Godin, MD, Alain Cribier, MD, PhD, Helene Eltchaninoff, MD, PhD Department of Cardiology, Charles Nicolle Hospital, INSERM U1096, University of Rouen, Institute for Research and nnovation in Biomedicine, Rouen, France; Department of Radiation Oncology and Medical Physics, Centre Henri Becquerel, Rouen, France.