Sylvain Trahan

Sex-related discordance between aortic valve calcification and hemodynamic severity of aortic stenosis : is valvular fibrosis the explanation?

Rationale: Calcific aortic stenosis (AS) is characterized by calcium deposition in valve leaflets. However, women present lower aortic valve calcification loads than men for the same AS hemodynamic severity. Objective: We, thus, aimed to assess sex differences in aortic valve fibrocalcific remodeling. Methods and Results: One hundred and twenty-five patients underwent Doppler echocardiography and multidetector computed tomography within 3 months before aortic valve replacement. Explanted stenotic tricuspid aortic valves were weighed, and fibrosis degree was determined. Sixty-four men and 39 women were frequency matched for age, body mass index, hypertension, renal disease, diabetes mellitus, and AS severity. Mean age (75±9 years), mean gradient (41±18 mm Hg), and indexed aortic valve area (0.41±0.12 cm2/m2) were similar between men and women (all P≥0.18). Median aortic valve calcification (1973 [1124–3490] Agatston units) and mean valve weight (2.36±0.99 g) were lower in women compared with men (both P<0.0001). Aortic valve calcification density correlated better with valve weight in men (r2=0.57; P<0.0001) than in women (r2=0.26; P=0.0008). After adjustment for age, body mass index, aortic valve calcification density, and aortic annulus diameter, female sex was an independent risk factor for higher fibrosis score in AS valves (P=0.003). Picrosirius red staining of explanted valves showed greater amount of collagen fibers (P=0.01), and Masson trichrome staining revealed a greater proportion of dense connective tissue (P=0.02) in women compared with men. Conclusions: In this series of patients with tricuspid aortic valve and similar AS severity, women have less valvular calcification but more fibrosis compared with men. These findings suggest that the pathophysiology of AS and thus potential targets for drug development may be different according to sex.

Angiotensin Receptor Blockers Are Associated with Reduced Fibrosis and Interleukin-6 Expression in Calcific Aortic Valve Disease

Background: Calcific aortic valve disease (CAVD) is a chronic disorder characterized by the mineralization of the aortic valve and involving fibrosis. Objectives: In this work we sought to determine if the fibrotic component of the remodeling process of CAVD was related to the use of angiotensin-converting enzyme inhibitors (ACEi) and/or angiotensin receptor blockers (ARBs). Methods: In 477 patients with CAVD, the aortic valve was examined by histology. A semiquantitative score of fibrosis was generated and associations with clinical/cardiometabolic variables examined. In a subset of 103 patients the aortic valve was available to study the infiltration by inflammatory cells and expression of interleukin-6 (IL-6) by quantitative real-time PCR. Results: The fibrosis score of the aortic valve was independently related to the hemodynamic severity of CAVD measured by echocardiography. The fibrotic score of the aortic valve was also related to the expression of IL-6. The use of ARBs but not of ACEi was associated with a lower fibrosis score of the aortic valve even after correction for covariates. In addition, patients under ARBs had lower aortic valve inflammation and expression of IL-6. Conclusions: These findings suggest that ARBs may alter the fibrotic process of the aortic valve in CAVD, possibly by lowering tissue inflammation.

Fatal Late Migration of Viacor Percutaneous Transvenous Mitral Annuloplasty Device Resulting in Distal Coronary Venous Perforation

We present the case of a patient with dilated ischemic cardiomyopathy and severe mitral regurgitation. Due to several comorbidities, he underwent percutaneous transvenous mitral annuloplasty. Postoperatively, he complained of atypical chest pain. He was treated for pericarditis and died suddenly 10 days after the procedure. Autopsy showed distal perforation of the anterior interventricular vein with migration of the device on the diaphragm.

Lipoprotein lipase in aortic valve stenosis is associated with lipid retention and remodelling

Calcific aortic valve disease (CAVD) is a chronic disorder characterized by a fibrocalcific remodelling. It is suspected that lipid retention within the aortic valve may be one important mechanism participating to aortic valve remodelling. Lipoprotein lipase (LPL) is implicated in lipid metabolism and may play a role in lipid retention within the aortic valve.

Large Free-Floating Intra-Aortic Thrombus

A 56-year-old woman was admitted with chronic chest and back pain with recent exacerbation. Cardiac enzyme levels and ECG were normal. Her history was positive for a patent ductus arteriosus ligation at 13 years of age and a total left mastectomy owing to cancer 4 months earlier. Her son died at 30 years of age as a result of type A aortic dissection. A chest computed …

Severe Aortic Regurgitation After Transradial Percutaneous Coronary Intervention

A 60-year-old man presented to a community hospital with new-onset shortness of breath after a 2-hour episode of typical chest pain. The ECG showed anteroseptal and inferior wall Q-waves. Serum troponin T levels were negative. An echocardiogram revealed anterior wall hypokinesia with left ventricular ejection fraction of 40% and no signs of valvular disease. The patient was transferred to our center for coronary angiography. Arterial access was obtained from the right radial artery. The angiogram showed mild disease of the left coronary artery and a right coronary artery (RCA) arising from the left coronary sinus. The RCA was extremely difficult to cannulate; nonselective injections revealed a long and severe stenosis of the mid segment (Figure 1 and Movie 1). After many unsuccessful attempts to cannulate the RCA with different guiding catheters, the operator decided to engage first the left coronary artery with an Amplatz 2 guiding catheter. A BMW Universal II guide wire was advanced into the left anterior descending artery (LAD) for better stability. This approach …

Appending Thrombus on Ulceration of the Ascending Aorta A Rare Cause of Acute ST-Elevation Myocardial Infarction

A 61-year-old man presented to the emergency department with typical acute chest pain of <4 hours duration. ECG showed 2-mm ST-segment elevations in inferior leads, and the cardiac catheterization team was called for primary percutaneous coronary intervention. Angiography of the right dominant coronary artery did not show significant lesion but distal embolization and slow flow (Figure 1). Angiography of the left coronary artery showed a moderate lesion in the left …A 61-year-old man presented to the emergency department with typical acute chest pain of 4 hours duration. ECG showed 2-mm ST-segment elevations in inferior leads, and the cardiac catheterization team was called for primary percutaneous coronary intervention. Angiography of the right dominant coronary artery did not show significant lesion but distal embolization and slow flow (Figure 1). Angiography of the left coronary artery showed a moderate lesion in the left anterior descending artery with a normal circumflex artery. Right anterior oblique ventriculography showed a severe posterobasal hypokinesia compatible with an acute inferior myocardial infarction. Left anterior oblique ventriculography showed moderate-severe inferior hypokinesia, and unexpectedly a large moving filling defect was visible in the ascending aorta just above the right coronary ostium (Figure 2 and online-only Data Supplement Movie). Urgent operation was carried out, and a segment of the aorta with the appending mass (Figure 3) was removed and replaced by a Dacron prosthesis. Microscopic examination showed an ulcerated intimal atheromatous plaque with adherent acute fibrinous thrombus (Figure 4A). Admixed leukocytes were present within the thrombus, but no granulation tissue or hemosiderin pigment was seen (Figure 4B). Staining for microorganisms was negative. No medial cystic degeneration or sign of aortitis was found. The patient made an uneventful recovery. In acute coronary syndrome, coronary embolization is sometimes suspected when no significant coronary stenosis can be found in the culprit artery. Our case illustrates that, in rare cases, myocardial infarction can be caused by embolization of thrombotic material originating from aortic ulceration.

Transcriptomic Microenvironment of Lung Adenocarcinoma

Background: Tissues surrounding tumors are increasingly studied to understand the biology of cancer development and identify biomarkers. Methods: A unique geographic tissue sampling collection was obtained from patients that underwent curative lobectomy for stage I pulmonary adenocarcinoma. Tumor and nontumor lung samples located at 0, 2, 4, and 6 cm away from the tumor were collected. Whole-genome gene expression profiling was performed on all samples (n = 5 specimens × 12 patients = 60). Analyses were carried out to identify genes differentially expressed in the tumor compared with adjacent nontumor lung tissues at different distances from the tumor as well as to identify stable and transient genes in nontumor tissues with respect to tumor proximity. Results: The magnitude of gene expression changes between tumor and nontumor sites was similar with increasing distance from the tumor. A total of 482 up- and 843 downregulated genes were found in tumors, including 312 and 566 that were consistently differentially expressed across nontumor sites. Twenty-nine genes induced and 34 knocked-down in tumors were also identified. Tumor proximity analyses revealed 15,700 stable genes in nontumor lung tissues. Gene expression changes across nontumor sites were subtle and not statistically significant. Conclusions: This study describes the transcriptomic microenvironment of lung adenocarcinoma and adjacent nontumor lung tissues collected at standardized distances relative to the tumor. Impact: This study provides further insights about the molecular transitions that occur from normal tissue to lung adenocarcinoma and is an important step to develop biomarkers in nonmalignant lung tissues. Cancer Epidemiol Biomarkers Prev; 26(3); 389–96. ©2016 AACR.

Fulminant pulmonary intravascular talcosis

ABSTRACT Pulmonary talcosis is still underrecognized. Two types of lung diseases have been described: talc pneumoconiosis and intravascular pulmonary talcosis. A young woman presenting with acute right ventricle failure as the initial presentation is reported.

Dysfunction of a bileaflet mechanical valve in mitral position: absence of symptoms despite a completely fixed leaflet.

We report the case of 62 year-old asymptomatic woman with a bileaflet mechanical prosthesis implanted 1 year ago. Routine transthoracic echocardiography (TTE) showed that one leaflet was fixed in semi-closed position, which was confirmed by transesophageal echocardiography (TEE) and cinefluoroscopy. The paradoxical absence of symptoms despite a complete restriction of one leaflet may be due to the fact that this patient had a very small body surface area and received a prosthesis with an excellent hemodynamic performance. The presence of a large compliant left atrial chamber may have also contributed to limit the effects of valve dysfunction on the pulmonary circulation.