Sophie Piérard

Prognostic Significance of LGE by CMR in Aortic Stenosis Patients Undergoing Valve Replacement

BACKGROUND Prior studies have shown that late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) can detect focal fibrosis in aortic stenosis (AS), suggesting that it might predict higher mortality risk. OBJECTIVES This study was conducted to evaluate whether LGE-CMR can predict post-operative survival in patients with severe AS undergoing aortic valve replacement (AVR). METHODS We prospectively evaluated survival (all-cause and cardiovascular disease related) according to LGE-CMR status in 154 consecutive AS patients (96 men; mean age: 74 ± 6 years) without a history of myocardial infarction undergoing surgical AVR and in 40 AS patients undergoing transcatheter aortic valve replacement (TAVR). RESULTS LGE was present in 29% of patients undergoing surgical AVR and in 50% undergoing TAVR. During a median follow-up of 2.9 years, 21 patients undergoing surgical AVR and 20 undergoing TAVR died. In surgical AVR, the presence of LGE predicted higher post-operative mortality (odds ratio: 10.9; 95% confidence interval [CI]: 1.2 to 100.0; p = 0.02) and worse all-cause survival (73% vs. 88%; p = 0.02 by log-rank test) and cardiovascular disease related survival (85% vs. 95%; p = 0.03 by log-rank test) on 5-year Kaplan-Meier estimates of survival after surgical AVR. Multivariate Cox analysis identified the presence of LGE (hazard ratio: 2.8; 95% CI: 1.3 to 6.9; p = 0.025) and New York Heart Association functional class III/IV (hazard ratio: 3.2; 95% CI: 1.1 to 8.1; p < 0.01) as the sole independent predictors of all-cause mortality after surgical AVR. The presence of LGE also predicted higher all-cause mortality (p = 0.05) and cardiovascular disease related mortality (p = 0.03) in the subgroup of patients without angiographic coronary artery disease (n = 110) and higher cardiovascular disease related mortality in 25 patients undergoing transfemoral TAVR. CONCLUSIONS The presence of LGE indicating focal fibrosis or unrecognized infarct by CMR is an independent predictor of mortality in patients with AS undergoing AVR and could provide additional information in the pre-operative evaluation of risk in these patients.

Incidence, Determinants, and Prognostic Impact of Operative Refusal or Denial in Octogenarians With Severe Aortic Stenosis

BACKGROUND Aortic stenosis (AS) is a common valve disease in octogenarians. Previous studies have shown that aortic valve replacement (AVR) is frequently not performed in these patients. This study investigated the incidence, determinants, and prognostic impact of AVR refusal or denial in these patients. METHODS Between 2000 and 2007, 163 octogenarians (mean age, 84 ± 3 years) with severe AS and an indication for operation according to guidelines were prospectively included in an echocardiographic registry. Among these, 97 underwent AVR, and 66 were treated conservatively. RESULTS Logistic regression analysis identified older age, a lower transaortic pressure gradient, a larger aortic valve area, and the presence of diabetes as independent predictors of AVR refusal or denial. Patients who underwent AVR had a 30-day mortality of 9%. Overall 5-year survival was 66% in AVR patients vs 31% in those treated conservatively (log rank p < 0.001 vs AVR). After adjustment for the propensity score, patients undergoing AVR still had a better outcome than conservatively treated patients (hazard ratio, 0.56; 95% confidence interval, 0.29 to 0.91; p = 0.022). In addition to the therapeutic decision, Cox regression analysis also identified low body weight, New York Heart Association class III/IV, and the logistic European System for Cardiac Operative Risk Evaluation as independent predictors of outcome in the overall series. CONCLUSIONS About 40% of octogenarians with severe AS and a definite indication for operation either refuse or are denied AVR. AVR refusal or denial has a profound impact on long-term prognosis, resulting in a twofold excess mortality, even after adjustment for the propensity score.

Aortic Valve Area, Stroke Volume, Left Ventricular Hypertrophy, Remodeling, and Fibrosis in Aortic Stenosis Assessed by Cardiac Magnetic Resonance Imaging Comparison Between High and Low Gradient and Normal and Low Flow Aortic Stenosis

Background—Recent works using echocardiography suggested that low gradient (LG), low flow (LF) aortic stenosis (AS) has more pronounced left ventricular (LV) concentric remodeling, smaller LV cavity size, and more interstitial fibrosis compared with high gradient (HG) normal flow (NF) AS. Therefore, we evaluated the accuracy of echocardiographic measurements and compared remodeling and fibrosis in different types of AS by cardiac magnetic resonance (CMR). Methods and Results—A total of 128 patients (73±11 years of age; 75 men) with aortic valve area (AVA) <0.6 cm2/m2 and ejection fraction >50% by echocardiography underwent CMR to measure planimetric AVA, phase-contrast indexed stroke volume, LV mass, and focal fibrosis. Using <40 mm Hg and indexed stroke volume <35 mL/m2 by echocardiography as criteria for LG and LF, 69 (54%) patients were HG/NF, 28 (22%) HG/LF, 17 (13%) LG/NF, and 14 (11%) LG/LF AS. LV outflow tract area, indexed stroke volume, and AVA correlated well between echocardiography and CMR (r=0.7, 0.61, and 0.65, respectively; P<0.001 for all). By CMR, however, planimetric AVA was larger in LF/LG (0.54±0.08 cm2/m2) and LG/NF (0.61±0.08 cm2/m2) than in HG/LF (0.46±0.07 cm2/m2; P<0.05) AS, and indexed LV mass was lower in LG/LF (75±12 g/m2) and LG/NF (81±18 g/m2) than in HG/LF (100±27 g/m2; P<0.05) AS. All groups of AS had similar LV volumes, predominantly concentric hypertrophy remodeling, and similar amounts of focal fibrosis. Conclusions—CMR confirmed overall accuracy of echocardiographic classification of AS but demonstrated that LG/LF and LG/NF AS have larger AVA, less LV hypertrophy, and similar focal fibrosis compared with HG/LF AS. This challenges the view that LG/LF AS is a more advanced state of AS.

Impact of preoperative symptoms on postoperative survival in severe aortic stenosis: implications for the timing of surgery

BACKGROUND The impact of symptoms on the natural history of patients with severe aortic stenosis (SAS) has been well documented. By contrast, the implications of preoperative symptoms on postoperative outcomes remain poorly defined. METHODS The long-term survival of 812 patients greater than 65 years old with SAS undergoing bioprosthetic aortic valve replacement (AVR) was analyzed according to their preoperative symptoms. RESULTS Operative mortality was larger in New York Heart Association (NYHA) III-IV than in NYHA I-II patients (10% vs 6%, p = 0.036). Abrupt symptomatic deterioration from NYHA I to NYHA III-IV within the month preceding surgery was observed in 18% of NYHA III-IV patients and resulted in an increased operative mortality (17% vs 5% in NYHA I, p = 0.035). Long-term survival was also significantly worse in NYHA III-IV than in NYHA I-II patients (56% vs 72%, p = 0.002). Reduced long-term survival of NYHA III/IV patients was observed in subgroups with a left ventricular ejection fraction (LVEF) 0.50 or greater (58 vs. 74%, p = 0.008) and in those with a systolic pulmonary artery pressure (SPAP) less than 40 mm Hg (60% vs 74%, p = 0.014). By contrast, the presence of class III-IV symptoms did not influence outcome in patients with a LVEF less than 0.50 (51 vs. 55%, p = 0.34) or with a SPAP 40 mm Hg or greater (43% vs 48%, p = 0.78). CONCLUSIONS In patients with SAS, preoperative NYHA III-IV symptoms, particularly of recent onset, are independently associated with excess short- and long-term postoperative mortality. This was particularly evident in patients with normal LV function or pulmonary artery pressures. These findings plead in favor of an earlier surgical correction of SAS, before the onset of severe symptoms, especially in low-risk patients.

Epithelial–myoepithelial carcinoma of the submandibular gland with symptomatic lung metastases treated with chemotherapy

This report concerns a patient with symptomatic lung metastases from an epithelial–myoepithelial carcinoma of the submandibular gland. Although the efficacy of chemotherapy is unknown in this disease, our patient was treated with cisplatin combined with 5-fluorouracil and later with paclitaxel and cyclophosphamide. Chemotherapy allowed disease stabilization and relief of the pulmonary symptoms. This is the first report on the use of chemotherapy in this very rare salivary gland carcinoma.

Inverted (Reverse) Takotsubo Cardiomyopathy following Cerebellar Hemorrhage

Background. First described in 2005, inverted takotsubo is one of the four stress-induced cardiomyopathy patterns. It is rarely associated with subarachnoid hemorrhage but was not previously reported after intraparenchymal bleeding. Purpose. We reported a symptomatic case of inverted takotsubo pattern following a cerebellar hemorrhage. Case Report. A 26-year-old woman presented to the emergency department with sudden headache and hemorrhage of the posterior fossa was diagnosed, probably caused by a vascular malformation. Several hours later, she developed acute pulmonary edema due to acute heart failure. Echocardiography showed left ventricular dysfunction with hypokinetic basal segments and hyperkinetic apex corresponding to inverted takotsubo. Outcome was spontaneously favorable within a few days. Conclusion. Inverted takotsubo pattern is a stress-induced cardiomyopathy that could be encountered in patients with subarachnoid hemorrhage and is generally of good prognosis. We described the first case following a cerebellar hematoma.

Should We Reappraise Surgical Indications in Asymptomatic Severe High-Gradient Aortic Stenosis?

T he optimal timing of aortic valve replacement in patients with severe aortic stenosis is not widely agreed upon. On the basis of retrospective autopsy data, it is generally believed that the prognosis of patients with no or minimal symptoms is relatively benign and that surgery can be safely delayed until symptoms develop (1). Accordingly, both the American Heart Association (AHA) and American College of Cardiology (ACC) and the European Society of Cardiology (ESC) guidelines consider symptomatic severe aortic stenosis as a class 1 indication for valve replacement but remain quite hesitant as to the optimal strategy to be adopted in asymptomatic patients (2,3). Over the past decade, many investigators have tried, almost desperately, to substantiate the “wait for symptoms” strategy promoted by the guidelines. What have we learned from these studies? First, asymptomatic severe aortic stenosis is not a benign but a deadly disease. In a large natural history study involving 622 consecutive asymptomatic patients with severe aortic stenosis followed up at the Mayo Clinic, Pellikka et al. (4) reported a 5-year survival probability of <60%. In a similar study involving 239 initially asymptomatic patients with severe aortic stenosis, Pai et al. (5) reported an even lower 3-year overall survival rate of 38%. Importantly, when reported, the primary cause of death in these initially asymptomatic patients was not sudden cardiac death, as feared by most cardiologists, but rather acute

Atrio-oesophageal fistula following atrial fibrillation ablation procedure: diagnosis with cardiac CT

A 74-year-old woman had an atrial fibrillation (AF) ablation procedure. Three weeks later, she presented with sepsis and paresis of the left upper limb. Initial chest computed tomography (CT) was inconclusive (Fig. 1a, b). Brain magnetic resonance imaging (MRI) showed acute multiple embolic cerebral infarcts (Fig. 1c, d). An atrio-oesophageal fistula (AOF) was suspected. ECG-gated CT was performed (Fig. 1e, f ), confirming the diagnosis. AOF should be considered in case of fever, neurological deficit or haematemesis following an AF ablation procedure. Transoesophageal echocardiography and oesophagogastroduodenoscopy are contraindicated because of risk of air embolization during these procedures. As a result of the subtle abnormalities in the left atrium and the cardiac motion, diagnosis with routine chest CT might be difficult. This case highlights the added value of cardiac CT in diagnosis of AOF, therefore allowing us to treat this serious complication.

Management of a Pregnant Woman With Fibromuscular Dysplasia.

A 39-year-old woman of Moroccan origin presented to the Cardiology Department with high blood pressure, with systolic blood pressure repeatedly measured at 170 mm Hg in the office. She was 10 days pregnant. Her treatment included nebivolol 5 mg and barnidipine 10 mg. Her medical history included migraines, an early miscarriage in 2001, and a second pregnancy with delivery at 27 weeks for preeclampsia in December 2014. At post-partum, she had received amlodipine, and then bisoprolol at another hospital. In September 2015, she had consulted at a third hospital for persistent hypertension with moderate to high blood pressure (systolic blood pressure: 170–190 mm Hg). Blood pressure was measured at 170/80 mm Hg in the office. Cardiac test results were normal. The physician concluded that the patient experienced chronic, rather than pregnancy-related hypertension, and replaced bisoprolol 5 mg with nebivolol 5 mg; barnidipine 10 mg was maintained, and the patient was asked to adhere to the therapeutic regimen. Despite mentioning that the hypertension was likely essential, he ordered an etiologic work-up. Renal function was normal (plasma creatinine: 58 μmol/L; estimated glomerular filtration rate: 100 mL/min per 1.73 m2). Urinary analysis revealed a mildly increased proteinuria of one-half gram per 24 hours. Urinary metanephrines were in the normal range, and the renal duplex study suggested a differential diagnosis of right renal artery stenosis and an arterial loop. Dr Micali: I would check the urinary sodium to confirm whether the patient is adhering to the hyposodic diet. This is one approach to check and determine whether the patient is consuming salt or not. Professor Persu: Yes, I think this is a good point, but this patient is not very adherent, and we had instances where we did not succeed in obtaining 24-hour urine samples. Additionally, this was performed in another hospital. I do not have …

Coronary vasospasm complicating cannabinoid hyperemesis syndrome

Cannabinoid hyperemesis syndrome (CHS) is a clinical condition that was first described in 2004. The syndrome may occasionally be observed in long-term cannabis users and is characterized by a set of features: severe cyclic nausea and vomiting, recurrent epigastric or periumbilical pain, relief of symptoms with hot baths, and cannabis use cessation. The pathophysiology is not fully understood but is probably related to Cannabinoid-1 (CB-1) receptors dysregulation. On the other hand, there is also growing epidemiological evidence that cannabis smoking may trigger acute coronary syndrome (ACS) in young men. We describe the case of 41-year-old man with a long history of cannabis smoking who not only complained of recurrent epigastric but also of retrosternal pain. He had undergone several negative radiological or endoscopic investigations. During the last episode, electrocardiographic and echocardiographic changes were consistent with takotsubo cardiomyopathy. However, the patient was readmitted very soon with a ST-elevation myocardial infarction related to coronary vasospasm. While the link between CHS and ACS is not established, CHS patients with atypical pain should be investigated carefully to exclude any serious cardiac event. <Learning objective: Cannabinoid hyperemesis syndrome is a rare medical entity than can be observed in some long-term heavy cannabis users. While most patients usually complain of recurrent epigastric or periumbilical pain with negative investigations, the possibility of some serious cardiac event should not be neglected as cannabis seems also able to trigger coronary vasospasm in patients presenting with atypical pain or electrocardiographic changes.>.