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ABSTRACT: Although mitral stenosis is mostly due to rheumatic fever, other etiologies, such as degenerative, congenital, drug- or radiotherapy-induced mitral stenosis, are emerging and need to be recognized in order to decide the best therapeutic options. This pictorial review describes the echocardiographic features of these different anatomical types and the additional value of three-dimensional echocardiography.
Archives of cardiovascular diseases 02/2013; 106(2):111-5. · 0.66 Impact Factor
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Claire Cimadevilla, Caroline Cueff,
Guillaume Hekimian,
Monique Dehoux,
Laurent Lepage,
Bernard Iung,
Xavier Duval,
Virginie Huart,
Florence Tubach,
Alec Vahanian,
David Messika-Zeitoun
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ABSTRACT: OBJECTIVE: Previous studies suggested an independent prognostic value of B-type natriuretic peptide (BNP) in aortic valve stenosis (AS) but were impeded by small sample sizes and inclusion of relatively selected young patients. We aimed to evaluate the relationship among N-terminal fragment of proBNP (Nt-proBNP), AS severity, symptoms and outcome in a large cohort of elderly patients with AS. DESIGN: Observational cohort study, COhorte Française de Retrecissement Aortique du Sujet Agé (clinicalTrial.gov number-NCT00338676) and GENEtique du Retrecissement Aortique (clinicalTrial.gov number-NCT00647088). SETTING: Single-centre study. PATIENTS: Patients older than 70 years with at least mild AS. INTERVENTIONS: None. MEASUREMENTS: A comprehensive clinical, biological and echocardiographic evaluation was performed at study entry. Asymptomatic patients were prospectively followed on a 6-months basis and AS-related events (sudden death, congestive heart failure or new onset of AS-related symptoms) collected. RESULTS: We prospectively enrolled 361 patients (79±6 years, 230 severe AS). Nt-proBNP increased with the grade of AS severity and the NYHA class (all p<0.0001) but there was an important overlap between grades/classes. Consequently, diagnostic value of Nt-proBNP for the diagnosis of severe symptomatic AS was only modest (area under the curve of the receiver operator characteristic analysis=0.73). At 2 years, 28 AS-related events occurred among 142 asymptomatic patients prospectively followed. Nt-proBNP was associated with outcome in univariate analysis (p=0.04) but not after adjustment for age, gender and AS severity (p=0.40). CONCLUSIONS: The present study clearly highlights the limitations of Nt-proBNP for the evaluation and management of AS patients. Our results suggest that Nt-proBNP should be considered cautiously, at least as a single criterion, in the decision-making process of AS patients especially in the elderly population.
Heart (British Cardiac Society) 01/2013; · 4.22 Impact Factor
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ABSTRACT: BACKGROUND: -Aortic Valve Calcification (AVC) is the intrinsic mechanism of valvular obstruction leading to aortic stenosis (AS) and is measurable by Multi-Detector-Computed-Tomography (MDCT). The link between gender and AS is controversial and that with AVC is unknown. METHODS AND RESULTS: -We prospectively performed MDCT in 665 patients with AS (Aortic-valve-area 1.05±0.35cm(2), Mean-gradient 39±19mmHg) to measure AVC and assess the impact of gender on the link AVC-AS severity in men and women. AS severity was comparable between women and men (Peak-Aortic-Jet-Velocity: 4.05±0.99 vs. 3.93±0.91m/s; p=0.11, Aortic-Valve-Area-index 0.55±0.20 vs. 0.56±0.18 cm(2)/m(2); p=0.46). Conversely, AVC load was lower in women vs. men (1703±1321 vs. 2694±1628AU, p<0.0001) even after adjustment for their smaller body-surface-area or aortic-annular-area (both p<0.0001). Thus, odds of high AVC load were much greater in men vs. women (Odds ratio 5.07, p<0.0001). While, AVC showed good associations with hemodynamic AS severity in men and women (all r>|0.67|, p<0.0001), for any level of AS severity measured by Peak-Aortic-Jet-Velocity or Aortic-Valve-Area-index, AVC load, absolute or indexed, was higher in men vs. women (all p≤0.01). CONCLUSIONS: -In this large AS population, women incurred similar AS severity than men for lower AVC loads, even after indexing for their smaller body-size. Hence, the relationship between valvular calcification process and AS severity differs in women vs. men warranting further patho-physiologic inquiry. For AS severity diagnostic purposes, interpretation of AVC load should be different in men and in women.
Circulation Cardiovascular Imaging 12/2012; · 5.94 Impact Factor
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Dominique Himbert,
Florence Pontnau,
David Messika-Zeitoun,
Fleur Descoutures,
Delphine Détaint, Caroline Cueff,
Martina Sordi,
Jean-Pierre Laissy,
Soleiman Alkhoder,
Eric Brochet,
Bernard Iung,
Jean-Pol Depoix,
Patrick Nataf,
Alec Vahanian
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ABSTRACT: Little is known about transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valve stenosis, which usually represents a contraindication. The aim of this study was to assess the feasibility and the results of TAVI in this patient subset. Of 316 high-risk patients with severe aortic stenosis who underwent TAVI from January 2009 to January 2012, 15 (5%) had documented bicuspid aortic valves. They were treated using a transarterial approach, using the Medtronic CoreValve system. Patients were aged 80 ± 10 years, in New York Heart Association functional classes III and IV. The mean aortic valve area was 0.8 ± 0.3 cm(2), and the mean gradient was 60 ± 19 mm Hg. The mean calcium score, calculated using multislice computed tomography, was 4,553 ± 1,872 arbitrary units. The procedure was successful in all but 1 patient. Major adverse events, according to Valvular Academic Research Consortium definitions, were encountered in 1 patient (death). The mean postimplantation prosthetic gradient was 11 ± 4 mm Hg, and ≤1+ periprosthetic leaks were observed in all but 2 patients. The mean prosthetic ellipticity index was 0.7 ± 0.2 at the level of the native annulus and 0.8 ± 0.2 at the level of the prosthetic leaflets. After a mean follow-up period of 8 ± 7 months, 1 patient had died from aortic dissection; there were no additional adverse events. All but 2 hospital survivors were in New York Heart Association class I or II. In conclusion, the present series suggests that transarterial Medtronic CoreValve implantation is feasible in selected patients with bicuspid aortic valve and may lead to short-term hemodynamic and clinical improvement.
The American journal of cardiology 06/2012; 110(6):877-83. · 3.58 Impact Factor
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Niall G Keenan,
Éric Brochet,
Jean-Michel Juliard,
Mihaela Malanca,
Pierre Aubry,
Laurent Lepage, Caroline Cueff,
Guillaume Jondeau,
Bernard Iung,
Alec Vahanian,
David Messika-Zeitoun
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ABSTRACT: No previous study has looked for an association between aortic dilatation and the clinical sequelae of patent foramen ovale (PFO), although a possible relationship has been identified in case reports.
To compare aortic dimensions in patients with symptomatic PFO and healthy controls.
Forty-seven patients were identified who presented with cryptogenic cerebrovascular accident (CVA) assessed as most likely secondary to PFO (confirmed by contrast study), were aged less than 50 years and underwent percutaneous PFO closure. Forty-seven age-, sex- and body surface area-matched healthy controls were also identified.
Aortic root diameters were greater in PFO patients. The difference was more marked at the levels of the sinuses of Valsalva (34±4 vs 31±3 mm, P<0.01) and the proximal ascending aorta (32±4 vs 29±3, P<0.01) and more modest at the level of the aortic annulus (23±3 vs 22±2 mm, P=0.20). In addition, patients with massive right-to-left shunting tended to have larger aortic diameters. In contrast, left ventricular end-systolic and end-diastolic diameters were not larger than in controls (30±4 vs 32±5 mm, P=0.10 and 48±5 vs 50±4 mm, P=0.04, respectively).
The present study shows that aortic diameter is increased in young patients with cryptogenic CVA and PFO compared with in healthy subjects. Our results suggest that aortic dilatation may potentiate the risk of CVA in PFO patients and support further research in this area.
Archives of cardiovascular diseases 01/2012; 105(1):13-7. · 0.66 Impact Factor
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European heart journal cardiovascular Imaging. 12/2011; 13(5):445.
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ABSTRACT: Patients with acute myocardial infarction (AMI) represent a high-risk population in which screening for abdominal aortic aneurysm (AAA) is recommended but only occasionally performed. Transthoracic echocardiography (TTE) may offer the unique opportunity to evaluate the cardiac function and to screen for AAA during the same examination. We aimed to evaluate the feasibility of AAA screening at bedside using a portable cardiac ultrasound (US) echo machine and to determine the prevalence of AAA in population with AMI.
The AA diameter was measured at bedside at the end of a regular TTE performed in consecutive patients admitted for AMI in the coronary care unit using a portable echo machine (Vividi, General Electric). AAA was defined by a transverse diameter of ≥ 30 mm. We prospectively enrolled 193 patients (65 ± 11 years, 77% male). Measurement of the AA diameter was feasible in 93% and the duration was 3 ± 1 min. An AAA was observed in nine patients (4.7%) and the prevalence increased with age (7.7% after 60 years and 9.2% after 65 years). No AAA was observed in patients under 50 years old. Inter-observer variability between cardiologists using the portable US system was excellent (mean difference 1.8 ± 2.0 mm) as well as the accuracy compared with measurements performed by a radiologist using a dedicated vascular US system (mean difference 1.5 ± 1.3 mm).
Overall, the prevalence of AAA was 4.7%, increased with age, and seems higher than expected in the 'same-aged population'. In regard to the simplicity, accuracy, and feasibility, screening for AAA during TTE (one cardiovascular shot) may be of value after AMI especially in elderly patients.
European heart journal cardiovascular Imaging. 11/2011; 13(7):574-8.
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ABSTRACT: Quantitative assessment of the severity of mitral regurgitation (MR) is based on the calculation of the effective regurgitant orifice (ERO), a measure of lesion severity, and of the regurgitant volume (RVol), a measure of left ventricular volume overload. We aimed at evaluating the determinants of RVol in both organic (OMR) and functional mitral regurgitation (FMR).
MR severity was quantitatively assessed using the proximal isovelocity surface area (PISA) method in 240 patients, 142 with OMR and 98 patients with FMR. By definition, ERO and RVol were strongly correlated both in patients with OMR and FMR (both R = 0.90, P < 0.0001) but the slopes of the regression lines were significantly different (P < 0.0001). This difference remained significant in patients with elevated systolic pulmonary artery pressure (SPAP > 40 mmHg, P < 0.0001) but not in patients with normal SPAP (≤40 mmHg, P = 0.09). In multivariate analysis, independent determinants of RVol were ERO (P < 0.0001), MR mechanism (FMR/OMR) (P = 0.0003) and SPAP (P = 0.03). In patients with elevated SPAP, ERO (P < 0.0001), left ventricular ejection fraction (LVEF) (P = 0.03), and MR mechanism (P = 0.03) were independently associated with RVol, whereas in patients with normal SPAP, ERO (P < 0.0001) was the only independent determinant of RVol.
In the present study, we evaluated the contrasting effect of similar lesion severity in OMR and FMR and showed that similar ERO were associated with lower RVol in FMR compared with OMR. The regurgitant volume is the result of complex interactions of anatomic lesions, LVEF, and SPAP and our results highlight the importance of taking into account these parameters when interpreting RVol values in clinical practice, especially in FMR.
European heart journal cardiovascular Imaging. 11/2011; 13(4):324-9.
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ABSTRACT: To assess the results of transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve System (MCS), through the transarterial approach, in high-risk patients with degenerated surgically implanted aortic bioprostheses (SP).
Of 241 patients who underwent TAVI, 10 (4%) had a degenerated SP. The approach was percutaneous transfemoral in 9 cases and surgical transaxillary in 1. Patients were age 75±10 years of age. All were in New York Heart Association classes III or IV and at high risk for repeated surgery. Seven patients had stented, 2 stentless, and 1 homograft SP. The failure mode was predominant regurgitation in 7 cases and stenosis (aortic valve area, 0.7±0.2 cm(2); mean gradient, 58±16 mm Hg) in 3. Based on the echographic measurements, 8 patients received a 26-mm, and 2 a 29-mm-diameter MCS. Procedural success rate was 100%. There was 1 in-hospital death, 1 stroke with moderate sequelae, and 1 pacemaker implantation. There were no other adverse events at 30 days. The mean postimplantation transprosthetic gradient was 13±7 mm Hg; periprosthetic regurgitation was absent or trivial in 9 cases and grade 2 in 1. After a median follow-up of 5 months, there were no additional adverse events. All but 1 of the hospital survivors were in New York Heart Association classes I or II.
These results suggest that transarterial MCS implantation in degenerated SP is feasible and may lead to hemodynamic and clinical improvement in patients who are poor candidates for repeated surgery, pending confirmation in larger series with longer follow-up.
Circulation Cardiovascular Interventions 09/2011; 4(5):488-94. · 6.06 Impact Factor
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ABSTRACT: Planimetry measured by two-dimensional transthoracic echocardiography (TTE, MVA2D) is the reference method for the evaluation of the severity of mitral stenosis (MS) but requires experienced operators and good echocardiographic windows. Real-time three-dimensional transoesophageal echocardiography (3D-TEE, MVA3D) may overcome these limitations but its accuracy has never been evaluated.
We prospectively enrolled 80 patients (58±15 years, 86% female) referred for MS evaluation who underwent, within 1 week, a clinically indicated TTE and TEE. MVA2D was measured by experienced operators (Level III), MVA3D by one experienced and one non-experienced (Level I) operators blinded of any clinical or TTE information. MVA3D measured by the experienced operator [1.11±0.32 cm2; median, 1.1 cm2; range (0.45-2.20)] did not differ from and correlated well with MVA2D [1.10±0.34 cm2; median, 1.05 cm2; range (0.45-2.30)], P=0.87; r=0.79, P<0.0001; ICC=0.79) and mean difference between methods was small (+0.004±0.21 cm2). MVA3D measured by the non-experienced operator [1.08±0.34 cm2; median 1.02 cm2; range (0.45-2.23)] also did not differ from and correlated well with MVA2D measured by experienced operators (P=0.25; r=0.86, P<0.0001; mean difference -0.02±0.18 cm2; ICC=0.86). Intra and interobserver variability were 0.02±0.25 and 0.01±0.33 cm2.
3D-TEE provides accurate and reproducible MVA measurements similar to 2D planimetry performed by experienced operators. Thus, 3D-TEE could be considered as a second-line alternative tool for the evaluation of MS severity in patients with poor echocardiographic windows or for team less accustomed to evaluate MS patients.
European Heart Journal – Cardiovascular Imaging 08/2011; 12(10):750-5. · 2.32 Impact Factor
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Caroline Cueff,
Jean-Michel Serfaty,
Claire Cimadevilla,
Jean-Pierre Laissy,
Dominique Himbert,
Florence Tubach,
Xavier Duval,
Bernard Iung,
Maurice Enriquez-Sarano,
Alec Vahanian,
David Messika-Zeitoun
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ABSTRACT: Measurement of the degree of aortic valve calcification (AVC) using electron beam computed tomography (EBCT) is an accurate and complementary method to transthoracic echocardiography (TTE) for assessment of the severity of aortic stenosis (AS). Whether threshold values of AVC obtained with EBCT could be extrapolated to multislice computed tomography (MSCT) was unclear and AVC diagnostic value in patients with low ejection fraction (EF) has never been specifically evaluated.
Patients with mild to severe AS underwent prospectively within 1 week MSCT and TTE. Severe AS was defined as an aortic valve area (AVA) of less than 1 cm(2). In 179 patients with EF greater than 40% (validation set), the relationship between AVC and AVA was evaluated. The best threshold of AVC for the diagnosis of severe AS was then evaluated in a second subset (testing set) of 49 patients with low EF (≤40%). In this subgroup, AS severity was defined based on mean gradient, natural history or dobutamine stress echocardiography.
Correlation between AVC and AVA was good (r=-0.63, p<0.0001). A threshold of 1651 arbitrary units (AU) provided 82% sensitivity, 80% specificity, 88% negative-predictive value and 70% positive-predictive value. In the testing set (patients with low EF), this threshold correctly differentiated patients with severe AS from non-severe AS in all but three cases. These three patients had an AVC score close to the threshold (1206, 1436 and 1797 AU).
In this large series of patients with a wide range of AS, AVC was shown to be well correlated to AVA and may be a useful adjunct for the evaluation of AS severity especially in difficult cases such as patients with low EF.
Heart (British Cardiac Society) 05/2011; 97(9):721-6. · 4.22 Impact Factor
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ABSTRACT: In patients with mitral stenosis (MS) in sinus rhythm (SR), guidelines recommend anticoagulation if the left atrium is enlarged based on diameter measurements. We sought to compare the association of left atrial (LA) diameter and LA volume with markers of thromboembolic risk (peak LA appendage emptying velocity [LAAv] and LA spontaneous contrast density) measured during transesophageal echocardiography in 152 patients with moderate to severe MS. High thromboembolic risk was defined by a peak LAAv < 25 cm/s and/or dense spontaneous contrast. Mean LA diameter (50 ± 7 mm, 32 to 77) and LA volume (152 ± 70 ml, 67 to 720) were significantly correlated (r = 0.71, p < 0.0001), but the relation was curvilinear and the 95% confidence interval increased with LA diameter. In the subset of 80 patients in SR who underwent clinically indicated transesophageal echocardiography, body surface area (BSA)-indexed LA volume but not LA diameter differentiated patients with normal from those with low LAAv (86 ± 17 vs 71 ± 17 ml/m(2), p < 0.01, and 50 ± 6 vs 48 ± 6 mm, p = 0.13, respectively) and patients with dense spontaneous contrast from those with no or mild spontaneous contrast (81 ± 16 vs 63 ± 15 ml/m(2), p < 0.01, and 49 ± 6 vs 46 ± 5 mm, p = 0.11, respectively). BSA-indexed LA volume provided the highest area under the curve (0.85) for high thromboembolic risk and LA diameter the lowest (0.65). A BSA-indexed LA volume > 60 ml/m(2) provided an excellent 90% sensitivity despite 44% specificity, 76% positive predictive value, and 70% negative predictive value. Use of this threshold instead of 50 or 55 mm would have changed the indication for anticoagulation in 51% to 77% of patients. In conclusion, LA volume was more strongly associated with markers of thromboembolic risk than LA diameter, which poorly reflected LA size. Our results support the use of BSA-indexed LA volume to guide the decision for anticoagulation in patients with MS in SR, which may lead to significant change in the management of those patients. We suggest a threshold of 60 ml/m(2), which has good sensitivity, albeit with low specificity.
The American journal of cardiology 10/2010; 106(8):1152-6. · 3.58 Impact Factor
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ABSTRACT: We present the case of a 42-year-old man who underwent tissue mitral valve replacement for symptomatic mitral stenosis. Post-operative course was unremarkable but three-dimensional transoesophageal echocardiography clearly indicated that one cusp had very restricted motion with incomplete opening and premature closure. The cause of this early single cusp failure is unclear. It was not related to flow effects. It is conceivable that cusp failure such as here might contribute towards the degeneration of tissue valve replacements.
European Heart Journal – Cardiovascular Imaging 05/2010; 11(9):E33. · 2.32 Impact Factor
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ABSTRACT: We sought to evaluate the relationship among left ventricular outflow tract diameter (LVOTd), gender, and body surface area (BSA) and to evaluate the usefulness of size-adjusted LVOTd reference values in patients with aortic stenosis (AS). AS grading is based on the echocardiographic calculation of the aortic valve area (AVA) and requires LVOTd measurements, one main potential source of error. Transesophageal echocardiography (TEE) is reputed to be more accurate than transthoracic echocardiography (TTE), but validation studies are rare. A safeguard for LVOTd measurements is thus desirable.
Since January 2006, 3 subsets of patients have been prospectively and concurrently enrolled: 1) TEE group: In 120 patients with and without AS, we prospectively measured LVOTd during both TTE and TEE. 2) Validation set: In 382 patients without aortic valve or ascending aorta diseases, we evaluated the relationship among LVOTd, gender, and BSA. 3) Testing set: In 173 patients with AS, we compared the AVA obtained using measured LVOTd (AVA(MEAS)) and calculated LVOTd derived from a regression determined in the validation set (AVA(CALC)).
TTE did not differ from and correlated well with TEE measurements overall (23 +/- 2 mm vs 23 +/- 2 mm, P = .26; r = 0.95, P < .0001) and in patients with AS (N = 43) (24 +/- 2 mm vs 24 +/- 3 mm, P = .15; r = 0.92, P < .0001). LVOTd was linearly correlated to BSA independently of gender (LVOTd = 5.7 * BSA+12.1; r = 0.55, P < .0001). In the testing set, AVA(CALC) did not differ from and correlated well with AVA(MEAS) (1.20 +/- 0.42 cm2 vs 1.23 +/- 0.40 cm2; P = .08; r = 0.89; P < .0001).
TTE and TEE measurements of the LVOTd provided similar results. LVOTd was significantly associated to BSA and LVOTd, derived from a linear regression linked to BSA independently of gender, provided an acceptable approximation of the AVA. Thus, although accurate measurement of LVOTd is a crucial part of the echocardiographic evaluation of AS severity, the present equation may be used as a safeguard when this measurement is difficult or not possible with TTE.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 04/2009; 22(5):445-51. · 2.98 Impact Factor
