Florent Le Ven

Laval University, Quebec City, Quebec, Canada

Are you Florent Le Ven?

Claim your profile

Publications (41)126.76 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: The aim of this study was to evaluate the presence, localisation and extent of myocardial injury as determined by late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging in patients undergoing transcatheter aortic valve implantation (TAVI). A total of 37 patients, who underwent successful TAVI with a balloon-expandable valve (transapical [TA], n=11; non-TA, n=26), were included. Cardiac biomarker (CK-MB and cTnT) levels were determined at baseline and following TAVI. CMR was performed within a week before and within 30 days following TAVI. Some increase in cardiac biomarkers was detected in 97% of the patients as determined by a rise in cTnT, and in 49% of the patients as determined by a rise in CK-MB. Following TAVI, no new myocardial necrosis defects were observed with the non-TA approach. Nonetheless, all patients who underwent TAVI through the TA approach had new focal myocardial necrosis in the apex, with a median myocardial extent and necrotic mass of 5% [2.0-7.0] and 3.5 g [2.3-4.5], respectively. Although some increase in cardiac biomarkers of myocardial injury was systematically detected following TAVI, new myocardial necrosis as evaluated by CMR was observed only in patients undergoing the procedure through the TA approach, involving ~5% of the myocardium in the apex.
    EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 06/2015; 11(2):205-213. DOI:10.4244/EIJV11I2A39 · 3.76 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: device, an average of 20% reduction of the septo-lateral diameter was observed (from 36±4 mm to 29±5 mm; p<0.01). Thirty-day mortality was 6.7% (adjudicated unrelated to the device). At 6 months follow up (N=17), 81% of patients were in NYHA class I-II with significant improvement in quality of life (MLWHFQ from 38 to 18; p<0.05) and 82% of patients had MR≤2+. Conclusions: Transseptal direct annuloplasty with an adjustable " surgical-like " ring is feasible, with a comparable safety profile similar to other transcatheter mitral procedures. Effective reduction in MR severity is observed in most patients related to a significant septo-lateral dimension reduction. MR reduction is stable and consistent at 6 months, with clinical benefit. Background: Progression of mitral valve prolapse (MVP) is known to be rapid in referral-based samples but longitudinal studies of MVP progression in the general population are lacking. Non-diagnostic morphologies (NDM) may represent early expression of MVP in those genetically predisposed. Our objective was to assess the echocardiographic features of MVP and NDM progression in the Framingham Heart Study. Methods: We measured changes in annular diameter (D), leaflet displacement (Dis), thickness (T), anterior/ posterior leaflet projections (A, P) onto the annulus, coaptation height (C = P/D), and mitral regurgitation (MR) jet height (JH) in 246 individuals of the Offspring cohort Exam 5 with available follow-up echo at either Exam 6 or 8 (11 to 17 years later). Study subjects included MVP (N=63), NDM-'minimal systolic displacement' or MSD (N = 50) and the 'abnormal anterior coaptation' (AAC) phenotype (N=10, with C > 40% of the annulus similar to posterior MVP), and 123 sex-and age-matched referents. Results: At follow-up, MVPs (50% women, mean age 57 ± 11 years) had greater increases of D, Dis, T, A, P and JH compared to referents (all p < 0.05). Eleven out of 63 MVPs (17%) had ≥ moderate MR (JH ≥ 5 mm) (2/11 with flail leaflet/JH > 7 mm, 11/11 with an average JH of 3 mm or mild MR at baseline), and additional 5/63 (8%) underwent mitral valve repair. Of the NDMs, 8/10 (80%) AACs progressed to posterior MVP, 17/50 (34%) MSDs were reclassified as either posterior MVP (12) or AAC (5). Compared with the 33 MSDs that didn't progress, the 17 that did progress had greater Dis, T, C, and JH, all p < 0.05. AACs reclassified as posterior MVP had on average mild MR (JH = 2.3 ± 1.4 mm) and C = 56 ± 4% at follow-up. Conclusion: MVP progresses to significant MR over a period of >10 years in one of 4 individuals in the community, suggesting that MVP may not be entirely benign as reported in previous cross-sectional studies. NDM may evolve into MVP, highlighting the clinical significance of mild MVP expression in the community. Changes in mitral leaflet morphology are associated with both MVP and NDM progression. Further studies are needed to identify the genetic and environmental factors influencing MVP progression.
    Journal of the American Society of Echocardiography; 06/2015
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Low flow (LF), defined as stroke volume index (SVi) <35 mL/m(2), prior to the procedure has been recently identified as a powerful independent predictor of early and late mortality in patients undergoing transcatheter aortic valve replacement (TAVR). The objectives of this study were to determine the evolution of SVi following TAVR and to assess the determinants and impact on mortality of early postprocedural SVi (EP-SVi). We retrospectively analysed the clinical, Doppler echocardiographic and outcome data prospectively collected in 255 patients who underwent TAVR. Echocardiograms were performed before (baseline), within 5 days after procedure (early post procedure) and 6 months to 1 year following TAVR (late post procedure). Patients with EP-SVi <35 mL/m(2) (n=138; 54%) had increased mortality (HR 1.97, p=0.003) compared with those with EP-SVi ≥35 mL/m(2) (n=117; 46%). Furthermore, patients with baseline SVi (B-SVi) <35 mL/m(2) and EP-SVI ≥35 mL/m(2), that is, normalised flow, had better survival (HR 0.46, p=0.03) than those with both B-SVi and EP-SVi <35 mL/m(2), that is, persistent LF, and similar survival compared with those with both B-SVi and EP-SVi ≥35 mL/m(2), that is, maintained normal flow. In a multivariable model analysis, EP-SVi was independently associated with increased risk of mortality (HR 1.41 per 10 mL/m(2) decrease, p=0.03). The preprocedural/intraprocedural factors associated with lower EP-SVi were lower B-SVi (standardised β [β] 0.36, p<0.001) atrial fibrillation (β -0.13, p=0.02) and transapical approach (β -0.22, p<0.001). The measurement of EP-SVi is useful to assess the immediate haemodynamic benefit of TAVR and to predict the risk of late mortality. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Heart (British Cardiac Society) 05/2015; DOI:10.1136/heartjnl-2014-307067 · 6.02 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The release of cardiac biomarkers of myocardial injury after transcatheter aortic valve replacement (TAVR) is common, but no data exist on patients undergoing TAVR through a transaortic approach. We aimed to evaluate the incidence and prognostic significance of the increase in cardiac biomarkers in nontransfemoral TAVR candidates, comparing transaortic and transapical approaches. After excluding patients deemed suitable for transfemoral TAVR, 251 consecutive patients (transaortic, 45; transapical, 206) were prospectively evaluated. Creatine kinase-myocardial band and cardiac troponin T levels were measured at baseline and at 6, 12, 24, 48, and 72 hours after TAVR. Baseline and 6- to 12-month echocardiographic and clinical follow-up were performed. After TAVR, cardiac troponin T increased above the upper normal values in all patients (peak value 0.64 μg/L [IQR, 0.39 to 1.03 μg/L]), whereas creatine kinase-myocardial band levels increased in 88% of patients (transaortic 51%, transapical 96%, p < 0.001; peak value 20.1 μg/L [interquartile range, 14.3 to 31.6 μg/L]). Compared with the transaortic approach, the transapical approach was associated with a greater rise in both cardiac biomarkers (p < 0.001 for both), and a lesser improvement in left ventricular ejection fraction (p = 0.058) and global longitudinal strain (p = 0.039) at 6- to 12-month follow-up. Greater increases of cardiac troponin T levels were independently associated with 30-day and 1-year overall and cardiovascular mortality (p < 0.001 for all). A 15-fold rise in cardiac troponin T levels was the optimal threshold for determining poorer outcomes (p < 0.001). Periprocedural TAVR-related myocardial injury in nontransfemoral candidates was demonstrated in all patients, but the transapical approach was associated with significantly greater myocardial injury compared with the transaortic approach. A higher degree of myocardial injury translated into reduced left ventricular function improvement and lower early and midterm survival rates. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    The Annals of thoracic surgery 04/2015; 99(6). DOI:10.1016/j.athoracsur.2015.01.029 · 3.65 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Low flow (LF) can occur with reduced (classic) or preserved (paradoxical) left ventricular ejection fraction (LVEF). The objective of this study was to compare outcomes of patients with low ejection fraction (LEF), paradoxical low flow (PLF), and normal flow (NF) after aortic valve replacement (AVR). We examined 1,154 patients with severe aortic stenosis (AS) who underwent AVR with or without coronary artery bypass grafting. Among these patients, 206 (18%) had LEF as defined by LVEF of <50%; 319 (28%) had PLF as defined by LVEF of ≥50% but stroke volume indexed to body surface area (SVi) of ≤35 ml ∙ m(-2); and 629 (54%) had NF, as defined by LVEF of ≥50% and SVi of >35 ml ∙ m(2). Aortic valve area was lower in low flow/LVEF groups (LEF: 0.71 ± 0.20 cm(2) and PLF: 0.65 ± 0.23 cm(2) vs. NF: 0.77 ± 0.18 cm(2); p < 0.001). The 30-day mortality was higher (p < 0.001) in LEF and PLF groups than in the NF group (6.3% and 6.3% vs. 1.8%, respectively). SVi and PLF group were independent predictors of operative mortality (odds ratio [OR]: 1.18, p < 0.05; and OR: 2.97, p = 0.004; respectively). At 5 years after AVR, overall survival was 72 ± 4% in LEF group, 81 ± 2% in PLF group, and 85 ± 2% in NF group (p < 0.0001). Patients with LEF or PLF AS have a higher operative risk, but pre-operative risk score accounted only for LEF and lower LVEF. Patients with LEF had the worst survival outcome, whereas patients with PLF and normal flow had similar survival rates after AVR. As a major predictor of perioperative mortality, SVi should be integrated in AS patients' pre-operative evaluation. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Cardiology 02/2015; 65(7):645-653. DOI:10.1016/j.jacc.2014.11.047 · 15.34 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Clinically discovering a systolic murmur is frequent among the young military population. When this murmur does not sound benign, a transthoracic echocardiography (TTE) is made to detect any cardiopathy, which could cause sudden cardiac death. The aim of this study was to evaluate the interest of systematic TTE in the assessment of any cardiac systolic murmur (CSM) among militaries.
    Annales de Cardiologie et d Angéiologie 02/2015; 64(2). DOI:10.1016/j.ancard.2015.01.016 · 0.30 Impact Factor
  • Archives of Cardiovascular Diseases Supplements 01/2015; 7(1):41. DOI:10.1016/S1878-6480(15)71605-8
  • Archives of Cardiovascular Diseases Supplements 01/2015; 7(1):31. DOI:10.1016/S1878-6480(15)71574-0
  • Archives of Cardiovascular Diseases Supplements 01/2015; 7(1):57. DOI:10.1016/S1878-6480(15)71655-1
  • [Show abstract] [Hide abstract]
    ABSTRACT: Calcific aortic valve disease affects 10%-15% of the elderly population, causing considerable morbidity and mortality. There is no imaging technique that allows for the assessment of tissue composition of the valve in vivo. We thus investigated whether multiparametric magnetic resonance imaging (MRI) could characterize and quantify lipid, fibrous, and mineralized tissues within aortic valve (AV) cusps. AV leaflets were explanted from patients with severe aortic stenosis at the time of valve replacement surgery. Aortic cusps were imaged ex vivo using 1.5T MRI using 3 gradient-echo sequences with T1, moderate T2, and proton density weightings (T1w, T2w, and PDw). Histopathologic analysis was performed on coregistered slices to identify and measure mineralized tissue, fibrous tissue, and lipid-rich tissue. Area and mean grey values were measured in all 3 weightings by standardized software. Four hundred ninety-two regions of interest from 30 AV leaflets were studied. Total leaflet surface and the areas of mineralized (P < 0.0001), fibrous (P = 0.002), and lipid-rich (P = 0.0001) tissues measured by MRI matched closely those measured by histopathologic examination. All 3 weightings provided significant discrimination between median grey values for mineralized, fibrous, and lipid-rich tissues (P < 0.0001 for T1w, moderate T2w, and PDw). A best-fit equation integrating the grey value data from all 3 weightings allowed multiparametric MRI to identify valve leaflet components with areas under the receiver operating characteristic curve of 0.92, 0.81, and 0.72, respectively. AV leaflet characteristics, including tissue composition, distribution, and area, may be successfully measured by multiparametric MRI with good to excellent accuracy. Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
    The Canadian journal of cardiology 12/2014; 30(12):1676-83. DOI:10.1016/j.cjca.2014.09.036 · 3.94 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Increased myocardial trabeculations define non-compaction cardiomyopathy (NCC). Imaging advancements have led to increasingly common identification of prominent trabeculations with unknown implications. We quantified and determined the impact of trabeculations’ burden on cardiac function and stretch in a population of healthy young adults. One hundred adults aged 18-35 (28±4 years, 55% women) without known cardiovascular disease were prospectively studied by cardiovascular magnetic resonance (CMR). Left ventricular (LV) volumes, segmental function, and ejection fraction (EF), and left atrial (LA) volumes were determined. Thickness and area of trabeculated (T) and dense (D) myocardium were measured for each standardized LV segment. N-terminal pro-brain natriuretic peptide (Nt-pro-BNP) was measured. Eighteen % of individuals had ≥1 positive traditional criteria for NCC and 11% meet new proposed NCC CMR criteria. T/D ratios were uniformly greater at end-diastole vs. end-systole (0.90±0.25 vs. 0.42 ±0.13, p<0.0001), in women vs. men (0.85±0.24 vs. 0.72±0.19, p=0.006), at anterior vs. non-anterior segments (1.41±0.59 vs. 0.88±0.35, p<0.0001), and at apical vs. non-apical segments (1.31±0.56 vs. 0.87±0.38, p<0.0001). The largest T/D ratios were associated with lower LVEF (57.0±5.3 vs. 62±5.5, p=0.0001) and greater Nt-pro-BNP (203±98 vs. 155±103, p=0.04). Multivariable regression identified greater end-systolic T/D ratios as the strongest independent predictor of lower LVEF, beyond age and gender, LA or LV volumes, and Nt-pro-BNP (β=-9.9, 95% CI -15-4.9, p<0.001). In conclusion, healthy adults possess variable amounts of trabeculations that regularly meet criteria for NCC. Greater trabeculations are associated with decreased LV function. Apparently healthy young adults with increased trabecular burden possess evidence of mildly impaired cardiac function.
    The American Journal of Cardiology 10/2014; 114(7). DOI:10.1016/j.amjcard.2014.07.025 · 3.43 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Recent studies have reported that obesity, metabolic syndrome, and diabetes are associated with LV hypertrophy (LVH) and dysfunction in aortic stenosis (AS) patients. The purpose of this study was to examine the association between amount and distribution of body fat and LVH and systolic dysfunction in AS patients. Methods 124 patients with AS were prospectively recruited in the PROGRESSA study and underwent Doppler-echocardiography and computed tomography (CT). Presence and severity of LVH was assessed by LV mass indexed for height2.7 (LVMi) and LV dysfunction by global longitudinal strain (GLS). CT was used to quantify abdominal visceral (VAT) and subcutaneous (SAT) adipose tissue, and total adipose tissue (TAT). Results Body mass index (BMI) correlated strongly with TAT (r=0.85), moderately with VAT (r=0.70), and SAT (r=0.69), and weakly with the proportion of VAT (VAT/TAT ratio: r=0.19). In univariate analysis, higher BMI, TAT, VAT, SAT, and VAT/TAT were associated with increased LVMi whereas higher VAT and VAT/TAT ratio were associated with reduced GLS. Multivariate analysis revealed that larger BMI (p<0.0001) and higher VAT/TAT ratio (p=0.01) were independently associated with greater LVH, whereas only the VAT/TAT ratio (p=0.03) was independently associated with reduced GLS. Conclusion This study suggests that both total and visceral adiposity are independently associated with LVH in AS patients. Furthermore, impairment of LV systolic function does not appear to be influenced by total obesity but is rather related to excess visceral adiposity. These findings provide impetus for elaboration of interventional studies aiming at visceral adiposity in AS population.
    The Canadian journal of cardiology 09/2014; 30(9). DOI:10.1016/j.cjca.2014.02.007 · 3.94 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background The transthoracic echocardiographic (TTE) evaluation of the severity of residual aortic regurgitation (AR) following transcatheter aortic valve implantation (TAVI) has been controversial and lacks validation. Objectives This study sought to compare TTE and cardiac magnetic resonance (CMR) for assessment of AR in patients undergoing TAVI with a balloon-expandable valve. Methods TTE and CMR exams were performed pre-TAVI in 50 patients and were repeated postprocedure in 42 patients. All imaging data were analysed in centralised core laboratories. Results The severity of native AR as determined by multiparametric TTE approach correlated well with the regurgitant volume and regurgitant fraction determined by CMR prior to TAVI (R-s=0.79 and 0.80, respectively; p<0.001 for both). However, after TAVI, the correlation between the prosthetic AR severity assessed by TTE and regurgitant volume and fraction measured by CMR was only modest (R-s=0.59 and 0.59, respectively; p<0.001 for both), with an underestimation of AR severity by TTE in 61.9% of patients (1 grade in 59.5%). The TTE jet diameter in parasternal view and the multiparametric approach (R-s=0.62 and 0.59, respectively; both with p<0.001) showed the best correlation with CMR regurgitant fraction post-TAVI. The circumferential extent of prosthetic paravalvular regurgitation showed a poor correlation with CMR regurgitant volume and fraction (R-s=0.32, p=0.084; R-s=0.36, p=0.054, respectively). Conclusions The severity of AR following TAVI with a balloon-expandable valve was underestimated by echocardiography as compared with CMR. The jet diameter, but not the circumferential extent of the leaks, and the multiparametric echocardiography integrative approach best correlated with CMR findings. These results provide important insight into the evaluation of AR severity post-TAVI.
    Heart (British Cardiac Society) 08/2014; 100(24). DOI:10.1136/heartjnl-2014-305615 · 6.02 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Aortic stenosis (AS) severity contributes to the left ventricle (LV) deterioration due to the aortic valve narrowing and the alteration of systemic hemodynamic load. This load increment may also increase the LV stroke work (SW) which represent the required energy to deliver the blood at ejection. In this study, SW was derived from in-vivo cardiovascular magnetic resonance (CMR) velocity measurements (n=57) using a lumped-parametric model. Furthermore, normalized SW (N-SW) was evaluated as AS severity parameter. SW differentiated from normal flow (>35 mL/m(2)) and low flow (<;35 mL/m(2)) states (p<;0.05). N-SW showed a good association with valve effective orifice area (EOA, r=-0.5, p<;0.001) and valvulo-arterial impedance (ZVA, r=0.65, p<;0.001). A severity threshold for N-SW (1.5 cJ/mL) was found using an EOA=1 cm(2) as AS severity marker. CMR-derived SW and N-SW may be useful to the assessment and grading of AS patients.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Little is known about the usefulness of evaluating cardiac neurohormones in patients undergoing transcatheter aortic valve implantation (TAVI). The objectives of this study were to evaluate the baseline values and serial changes of N-terminal prohormone B-type natriuretic peptide (NT-proBNP) after TAVI, its related factors, and prognostic value. A total of 333 consecutive patients were included, and baseline, procedural, and follow-up (median 20 months, interquartile range 9 to 36) data were prospectively collected. Systematic NT-proBNP measurements were performed at baseline, hospital discharge, 1, 6, and 12 months, and yearly thereafter. Baseline NT-proBNP values were elevated in 86% of the patients (median 1,692 pg/ml); lower left ventricular ejection fraction and stroke volume index, greater left ventricular mass, and renal dysfunction were associated with greater baseline values (p <0.01 for all). Higher NT-proBNP levels were independently associated with increased long-term overall and cardiovascular mortalities (p <0.001 for both), with a baseline cut-off level of ∼2,000 pg/ml best predicting worse outcomes (p <0.001). At 6- to 12-month follow-up, NT-proBNP levels had decreased (p <0.001) by 23% and remained stable up to 4-year follow-up. In 39% of the patients, however, there was a lack of NT-proBNP improvement, mainly related to preprocedural chronic atrial fibrillation, lower mean transaortic gradient, and moderate-to-severe mitral regurgitation (p <0.01 for all). In conclusion, most patients undergoing TAVI presented high NT-proBNP levels, and a lack of improvement was observed in >1/3 of the patients after TAVI. Also, higher NT-proBNP levels predicted greater overall and cardiac mortalities at a median follow-up of 2 years. These findings support the implementation of NT-proBNP measurements for the clinical decision-making process and follow-up of patients undergoing TAVI.
    The American journal of cardiology 03/2014; 113(5):851-9. DOI:10.1016/j.amjcard.2013.11.038 · 3.43 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Early detection and accurate estimation of aortic stenosis (AS) severity are the most important predictors of successful long-term outcomes in patients. Current clinical parameters used for evaluation of the AS severity have several limitations including flow dependency. Estimation of AS severity is specifically challenging in patients with low-flow and low transvalvular pressure gradient conditions. A proper diagnosis in these patients needs a comprehensive evaluation of the left ventricle (LV) hemodynamic loads. This study has two objectives: (1) developing a lumped-parameter model to describe the ventricular-valvular-arterial interaction and to estimate the LV stroke work (SW); (2) introducing and validating a new index, the normalized stroke work (N-SW), to assess the global hemodynamic load imposed on the LV. N-SW represents the global hemodynamic load that the LV faces for each unit volume of blood ejected. The model uses a limited number of parameters which all can be measured non-invasively using current clinical imaging modalities. The model was first validated by comparing its calculated flow waveforms with the ones measured using Cardiovascular Magnetic Resonance (CMR) in 49 patients and 8 controls. A very good correlation and concordance were found throughout the cycle (median root mean square: 12.21 mL/s) and between the peak values (r = 0.98; SEE = 0.001, p<0.001). The model was then used to determine SW using the parameters measured with transthoracic Doppler-echocardiography (TTE) and CMR. N-SW showed very good correlations with a previously-validated index of global hemodynamic load, the valvular arterial impedance ([Formula: see text]), using data from both imaging modalities (TTE: r = 0.82, SEE = 0.01, p<0.001; CMR: r = 0.74, SEE = 0.01, p<0.001). Furthermore, unlike , N-SW was almost independent from variations in the flow rate. This study suggests that considering N-SW may provide incremental diagnostic and prognostic information, beyond what standard indices of stenosis severity and provide, particularly in patients with low LV outflow.
    PLoS ONE 01/2014; 9(1):e86793. DOI:10.1371/journal.pone.0086793 · 3.53 Impact Factor
  • Cardiology; 01/2014
  • Cardiology; 01/2014
  • The Canadian journal of cardiology 10/2013; 29(10):S381. DOI:10.1016/j.cjca.2013.07.655 · 3.94 Impact Factor
  • The Canadian journal of cardiology 10/2013; 29(10):S160. DOI:10.1016/j.cjca.2013.07.239 · 3.94 Impact Factor

Publication Stats

123 Citations
126.76 Total Impact Points

Institutions

  • 2014–2015
    • Laval University
      • • Institut Universitaire de Cardiologie et de Pneumologie de Québec
      • • Department of Surgery
      Quebec City, Quebec, Canada
    • Institut universitaire de cardiologie et de pneumologie de Québec
      Quebec City, Quebec, Canada
  • 2011–2012
    • ESC Bretagne Brest
      Brest, Brittany, France
  • 2010
    • Centre Hospitalier Universitaire de Brest
      Brest, Brittany, France