Thierry Bourguignon

How to define valvular atrial fibrillation

Atrial fibrillation (AF) confers a substantial risk of stroke. Recent trials comparing vitamin K antagonists (VKAs) with non-vitamin K antagonist oral anticoagulants (NOACs) in AF were performed among patients with so-called non-valvular AF. The distinction between valvular and non-valvular AF remains a matter of debate. Currently, valvular AF refers to patients with mitral stenosis or artificial heart valves (and valve repair in North American guidelines only), and should be treated with VKAs. Valvular heart diseases, such as mitral regurgitation, aortic stenosis (AS) and aortic insufficiency, do not result in conditions of low flow in the left atrium, and do not apparently increase the risk of thromboembolism brought by AF. Post-hoc analyses suggest that these conditions probably do not make the thromboembolic risk less responsive to NOACs compared with most forms of non-valvular AF. The pathogenesis of thrombosis is probably different for blood coming into contact with a mechanical prosthetic valve compared with what occurs in most other forms of AF. This may explain the results of the only trial performed with a NOAC in patients with a mechanical prosthetic valve (only a few of whom had AF), where warfarin was more effective and safer than dabigatran. By contrast, AF in the presence of a bioprosthetic heart valve or after valve repair appears to have a risk of thromboembolism that is not markedly different from other forms of non-valvular AF. Obviously, we should no longer consider the classification of AF as valvular (or not) for the purpose of defining the aetiology of the arrhythmia, but for the determination of a different risk of thromboembolic events and the need for a specific antithrombotic strategy. As long as there is no better new term or widely accepted definition, valvular AF refers to patients with mitral stenosis or artificial heart valves. Patients with non-valvular AF may have other types of valvular heart disease. One should emphasize that non-valvular AF does not exclude patients with some types of valvular heart disease from therapy with NOACs.

Very late outcomes for mitral valve replacement with the Carpentier-Edwards pericardial bioprosthesis: 25-year follow-up of 450 implantations.

OBJECTIVEnThe aim of the present study was to evaluate the very-long-term results of the Carpentier-Edwards pericardial bioprosthesis in the mitral position.nnnMETHODSnFrom 1984 to 2011, 450 Carpentier-Edwards PERIMOUNT pericardial mitral bioprostheses were implanted in 404 consecutive patients (mean age, 68 years; 53% female). Patients undergoing multiple valve replacements were excluded. The clinical, operative, and follow-up data were prospectively recorded. The mean follow-up was 7.2±5.1 years, for a total of 3258 valve-years. The follow-up data were 97.8% complete.nnnRESULTSnThe operative mortality rate was 3.3%. A total of 188 late deaths occurred, for a linearized rate of 5.8%/valve-year. At 20 years, the overall actuarial survival rate was 16.9%±3.9%. Age at implantation, preoperative New York Heart Association class III or IV, and redo procedure were significant risk factors affecting late survival. The actuarial freedom from complications at 20 years was thromboembolism, 83.9%±7.6%; hemorrhage, 80.2%±10.8%; endocarditis, 94.8%±1.4%; structural valve deterioration, 23.7%±6.9%; and explantation owing to structural valve deterioration, 40.5%±8.0%. The competing risk analysis demonstrated an actual risk of explantation owing to structural valve deterioration at 20 years of 25.5%±2.9%. The expected valve durability was 16.6 years for the entire cohort (11.4, 16.6, and 19.4 years for patients aged <60, 60 to 70, and >70 years, respectively).nnnCONCLUSIONSnWith a low rate of valve-related events at 20 years and, in particular, a low rate of structural valve deterioration, the Carpentier-Edwards PERIMOUNT pericardial bioprosthesis remains a reliable choice for a mitral tissue valve, especially in patients >60 years old.

Prognostic value of CHA2DS2-VASc score in patients with ‘non-valvular atrial fibrillation’ and valvular heart disease: the Loire Valley Atrial Fibrillation Project

AIMSnThe CHA2DS2VASc score is a clinical risk stratification tool which estimates the risk of stroke and thromboembolism in non-valvular atrial fibrillation (AF). We aimed to establish the value of this score for risk evaluation in patients with non-valvular AF and valvular heart disease.nnnMETHODS AND RESULTSnAmong 8053 patients with non-valvular AF (ESC guidelines definition), patients were categorized into Group 1 (no valve disease, n = 6851; 85%) and Group 2 (valve disease with neither rheumatic mitral stenosis nor valve prothesis, n = 1202; 15%). After follow-up of 868 ± 1043 days, 627 stroke/ thromboembolic (TE) events were recorded. Group 2 was significantly older, had a higher CHA2DS2VASc score and had a higher risk of thromboembolic events [hazard ratio (HR) 1.39; 95% CI 1.14-1.69, P = 0.001] compared with Group 1. Severe valve disease was not associated with worse prognosis for stroke/TE events. In the two groups, stroke/TE risk increased with a higher CHA2DS2VASc score. Factors independently associated with increased risk of stroke/TE events were older age (HR 1.25, 95% CI 1.14-1.36 per 10-year increase, P < 0.0001) and higher CHA2DS2VASc score (HR 1.33, 95% CI 1.23-1.45, P < 0.0001). The predictive value (c-statistic) of the CHA2DS2VASc score was similar in the two groups.nnnCONCLUSIONnIn patients with non-valvular AF, left-sided valvular heart disease (excluding mitral stenosis and protheses) was associated with an increased risk of stroke/TE events. A higher CHA2DS2VASc score in these patients is likely to explain these results.

Oral anticoagulation, stroke and thromboembolism in patients with atrial fibrillation and valve bioprosthesis. The Loire Valley Atrial Fibrillation Project.

Vitamin K antagonists are currently recommended in patients with valvular atrial fibrillation (AF), e.u2009g. those having mitral stenosis or artificial heart valves. We compared thromboembolic risk in patients with non valvular AF and in those with AF and biological valve replacement (valve bioprosthesis). Among 8962 AF patients seen between 2000 and 2010, a diagnosis of non-valvular AF was found in 8053 (94u2009%). Among patients with valvular AF, 549 (6u2009%) had a biological prosthesis. The patients with bioprosthesis were older and had a higher CHA2DS2-VASc score than those with non valvular AF. After a follow-up of 876 ± 1048 days (median 400 days, interquartile range 12-1483), the occurrence of thromboembolic events was similar in AF patients with bioprosthesis compared to those with non valvular AF (hazard ratio [HR] 1.10 95u2009% confidence interval [CI] 0.83-1.45, p=0.52, adjusted HR 0.93, 95u2009%CI 0.68-1.25, p=0.61). Factors independently associated with increased risk of stroke/TE events were older age (HR 1.25, 95u2009%CI 1.16-1.34 per 10-year increase, p<u20090.0001) and higher CHA2DS2-VASc score (HR 1.35, 95u2009%CI 1.24-1.46, p<u20090.0001) whilst female gender (HR 0.75, 95u2009%CI 0.62-0.90, p=0.002), use of vitamin K antagonist (HR 0.83, 95u2009%CI 0.71-0.98, p=0.03) were independently associated with a lower risk of stroke/TE. Neither the presence of bioprosthesis nor the location of bioprosthesis was independent predictor for TE events. In conclusion, AF patients with bioprosthesis had a non-significantly higher risk of stroke/TE events compared to patients with non-valvular AF. Second, the CHA2DS2-VASc score was independently associated with an increased risk of TE events, and was a valuable determinant of TE risk both in AF patients with non-valvular AF as well as those with bioprosthesis, whether treated or not treated with OAC.

A 25-year experience with Carpentier-Edwards Perimount in the mitral position.

Data of 401 patients who underwent mitral valve replacement with the Carpentier-Edwards Perimount bioprosthesis between 1984 and 2009 were evaluated. Their mean age was 68.1u2009±u200910.4 years (range, 22–90 years) and 54.9% were female. The most common etiology was degenerative disease (33.2%) and 62.1% of patients had mitral insufficiency. Follow-up was 3,178 patient-years, and 96.8% complete; the mean follow-up was 8.9u2009±u20093.1 years. Overall survival at 25 years was 10.2%u2009±u20093%. Late mortality was 2.48% per patient-year, and valve-related deaths occurred at 1.62% per patient-year. The actuarial freedom from reoperation due to structural valve deterioration at 20 years was 24.3%u2009±u20092% for degenerative disease and 15%u2009±u20091.4% for non-degenerative disease. For degenerative valve disease, the freedom from structural valve deterioration at 18-years was 39%u2009±u20091% for recipients <60-years old and 66%u2009±u20092% for those ≥60-years old. Our data confirm the excellent durability and low mortality associated with the Carpentier-Edwards Perimount for mitral valve replacement. The rate of calcification of the valve was unrelated to degenerative valve disease, but our findings suggest that this prothesis gives better results in recipients ≥60-years old than in younger patients.

Long-Term Outcome and Valve Surgery for Infective Endocarditis in the Systematic Analysis of a Community Study

BACKGROUNDnInformation on the long-term prognosis of patients with infective endocarditis (IE) and valve surgical procedures is scarce, and most analyses are based on registries. This study described outcomes and predictors of mortality in a cohort of consecutive patients with IE with a long-term follow-up.nnnMETHODSnA total of 616 of patients with IE seen in an academic institution between 1990 and 2012 were identified and followed. The mean follow-up period was 4.8 ± 5.7 years (median, 2.6 years).nnnRESULTSnCardiac surgical procedures were performed in 47% of the patients, among whom 77% had surgical procedures in the first 6 months. Six-month and long-term (≥6 month) mortality rates were 15% and 40%, respectively. Older age, male sex, infection in a mechanical valve, Staphylococcus aureus infection, presence of vegetation, stroke, and atrioventricular block were independent predictors of mortality, whereas Streptococcus infection was independently associated with a better prognosis. Valve surgical procedures were independently associated with a decrease in mortality: hazard ratio (HR): 0.38; 95% confidence interval (CI): 0.26 to 0.56 for surgical treatment within 45 days; HR 0.36; 95% CI: 0.22 to 0.61 for surgical treatment between 45 and 180 days; and HR: 0.42; 95% CI: 0.25 to 0.73 for surgical treatment beyond 6xa0months. Decrease in mortality with valve surgical procedures was found in the two subgroups of patients with definite IE (adjusted HR: 0.36; 95% CI: 0.24 to 0.54; p < 0.0001) and in those with possible IE (HR: 0.40; 95% CI: 0.24 to 0.67; pxa0= 0.0005).nnnCONCLUSIONSnIn unselected patients with IE, prognostic factors for long-term mortality were consistent with those identified in previous studies for short-term mortality. These results confirm the apparent benefit associated with valve surgical procedures on long-term prognosis.

Comparison of Outcome of Possible Versus Definite Infective Endocarditis Involving Native Heart Valves

There are very few data on the prognosis of possible versus definite infective endocarditis (IE). We studied data from 365 consecutive patients with IE involving native heart valve seen in an academic institution from 1990 to 2012. Patients were classified according to the modified Duke criteria for IE: patients with possible IE (nxa0= 101, 28%) and those with definite IE (nxa0= 264, 72%). Patients with possible IE were older than those with definite IE (66 ± 15 vs 62 ± 16, pxa0= 0.05). A causative microorganism was identified in 66% of patients with possible IE versus all patients with definite IE (p <0.0001) and only 41% had major echocardiographic criteria (vs 100%; p <0.0001). Overall, 139 patients died over a meanxa0±xa0SD follow-up of 3.9 ± 4.5xa0years (median 2.2, interquartile range 5.9xa0years). Patients with possible and definite IE had a similar risk of death. Independent predictors of long-term mortality were increasing age (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.01 to 1.04; pxa0= 0.0009), vegetation length >15xa0mm (HR 1.87, 95% CI 1.14 to 3.06; pxa0=xa00.01), and stroke (HR 4.10, 95% CI 1.84 to 9.17; pxa0= 0.0006), whereas infection of mitral valve (HR 0.57, 95% CI 0.34 to 0.94; pxa0= 0.03) and surgery (HR 0.43, 95% CI 0.19 to 0.99; pxa0=xa00.05) were associated with a better prognosis. Patients with definite IE and those with possible IE who did not undergo surgery had a worse prognosis than their counterparts with surgery. In conclusion, unselected patients with possible IE (Duke criteria) had a similar prognosis than those with definite IE.

Prediction of Systemic Septic Embolism in Patients With Left-Sided Infective Endocarditis

Embolic complications (EC) may occur in 10% to 45% of patients with left-sided infective endocarditis (LSIE). These EC mainly affect the central nervous system and therefore worsen prognosis. Two systems have recently been designed for predicting embolic risk in LSIE. We evaluated their prognostic

Comparison of Outcome of Possible Versus Definite Infective Endocarditis Involving Prosthetic or Bioprosthetic Heart Valves

The objectives of this study were to describe and compare the clinical characteristics and outcomes of patients with definite and possible infective endocarditis (IE) involving prosthetic heart valve, and to identify prognostic factors for long-term mortality, using data from an unselected cohort of consecutive patients. We studied data from 133 consecutive patients with IE involving prosthetic heart valve seen in an academic institution between 1990 and 2012. Patients were classified according to the modified Duke criteria for IE: patients with possible IE (nu2009=u200947, 35%) and patients with definite IE (nu2009=u200986, 65%). Overall, 55 patients died over a meanu2009±u2009SD follow-up of 3.6u2009±u20094.1 years (median 1.8, interquartile range 4.4 years). Patients with definite IE had a higher risk of death (hazard ratio [HR] 2.21, 95% confidence interval [CI] 1.20 to 4.17 pu2009=u20090.01). Independent predictors of long-term mortality were increasing age (HR 1.05, 95% CI 1.02 to 1.08, pu2009=u20090.002), Staphylococcus aureus infection (HR 3.40, 95% CI 1.00 to 11.76; pu2009=u20090.05), infection with unknown microorganism (HR 12.50, 95% CI 2.97 to 52.63; pu2009=u20090.0006), and definite IE (HR 8.70, 95% CI 3.55 to 21.28; pu2009<0.0001), whereas infection on pacemaker or defibrillator (HR 0.30, 95%CI 0.10 to 0.87; pu2009=u20090.03) was associated with a better prognosis. Patients with definite IE and those with possible IE who underwent surgery had a nonsignificantly better prognosis than their counterparts with no surgery. In conclusion, patients with definite IE (Duke criteria) on a prosthetic heart valve independently had a worse prognosis than those with possible IE.