[Cardiac surgery in the time of COVID19 - A narrative of three very unusual cases and lessons learned]. / Chirurgie cardiaque au temps du Covid-19 - Récit de trois cas très inhabituels et leçons retenues.

COVID19 altered and impacted medical and surgical practice around the world. Standard of care and routine procedures are disrupted. Majors shift in personnel, and ad hoc new team as well as delocalization and working with new infrastructures are further challenges to be dealt with. This review of three very unusual scenarios illustrates pitfalls and dangers harbored in the re-shaped landscape of COVID19 exemplifying the narrow path bridging from the medical and surgical comfort zone to uncharted territory and eventually leading to collateral damage.

Le Covid-19 a profondément modifié et sévèrement impacté les pratiques médicales et chirurgicales à long terme. Les standards de prise en charge et les procédures de routine sont altérés, voire perturbés. Des mutations majeures au niveau du personnel et des équipes de même que la délocalisation ou le travail avec de nouvelles infrastructures sont autant de défis à relever, encore aujourd'hui. Trois scénarios inhabituels illustrent les pièges et les dangers qui se cachent dans le paysage marqué par le Covid-19. Ces exemples démontrent la marge étroite entre la zone de confort médicale et chirurgicale classique et l'appréhension d'une situation inhabituelle qui risque d'entraîner des dommages collatéraux pour les patients.

Biomechanics of diastolic dysfunction: a one-dimensional computational modeling approach.

Diastolic dysfunction (DD) is a major component of heart failure with preserved ejection fraction (HFpEF). Accordingly, a profound understanding of the underlying biomechanical mechanisms involved in DD is needed to elucidate all aspects of HFpEF. In this study, we have developed a computational model of DD by leveraging the power of an advanced one-dimensional arterial network coupled to a four-chambered zero-dimensional cardiac model. The two main pathologies investigated were linked to the active relaxation of the myocardium and the passive stiffness of the left ventricular wall. These pathologies were quantified through two parameters for the biphasic delay of active relaxation, which simulate the early and late-phase relaxation delay, and one parameter for passive stiffness, which simulates the increased nonlinear stiffness of the ventricular wall. A parameter sensitivity analysis was conducted on each of the three parameters to investigate their effect in isolation. The three parameters were then concurrently adjusted to produce the three main phenotypes of DD. It was found that the impaired relaxation phenotype can be replicated by mainly manipulating the active relaxation, the pseudo-normal phenotype was replicated by manipulating both the active relaxation and passive stiffness, and, finally, the restricted phenotype was replicated by mainly changing the passive stiffness. This article presents a simple model producing a holistic and comprehensive replication of the main DD phenotypes and presents novel biomechanical insights on how key parameters defining the relaxation and stiffness properties of the myocardium affect the development and manifestation of DD.NEW & NOTEWORTHY This study uses a complete and validated computational model of the cardiovascular system to simulate the two main pathologies involved in diastolic dysfunction (DD), i.e., abnormal active relaxation and increased ventricular diastolic stiffness. The three phenotypes of DD were successfully replicated according to literature data. We elucidate the biomechanical effect of the relaxation pathologies involved and how these pathologies interact to create the various phenotypes of DD.

Acute effects of transcatheter aortic valve replacement on the ventricular-aortic interaction.

Transcatheter aortic valve replacement (TAVR) is increasingly used to treat severe aortic stenosis (AS) patients. However, little is known regarding the direct effect of TAVR on the ventricular-aortic interaction. In the present study, we aimed to investigate changes in central hemodynamics after successful TAVR. We retrospectively examined 33 cases of severe AS patients (84 ± 6 yr) who underwent TAVR. Invasive measurements of left ventricular and aortic pressures as well as echocardiographic aortic flow were acquired before and after TAVR (maximum within 5 days). We examined alterations in key features of central pressure and flow waveforms, including the aortic augmentation index (AIx), and performed wave separation analysis. Arterial parameters were determined via parameter-fitting on a two-element Windkessel model. Resolution of AS resulted in direct increase in the aortic systolic pressure and maximal aortic flow (131 ± 22 vs. 157 ± 25 mmHg and 237 ± 49 vs. 302 ± 69 mL/s, P < 0.001 for all), whereas the ejection duration decreased (P < 0.001). We noted a significant decrease in the AIx (from 42 ± 12 to 19 ± 11%, P < 0.001). Of note, the arterial properties remained unchanged. There was a comparable increase in both forward (61 ± 20 vs. 77 ± 20 mmHg, P < 0.001) and backward (35 ± 14 vs. 42 ± 10 mmHg, P = 0.013) pressure wave amplitudes, while their ratio, i.e., the reflection coefficient, was preserved. Our results highlight the impact of TAVR on the ventricular-aortic interaction by affecting the amplitude, shape, and related attributes of the aortic pressure and flow pulse and challenge the interpretation of AIx as a solely vascular measure in AS patients.NEW & NOTEWORTHY Transcatheter aortic valve replacement (TAVR) is linked with an immediate increase in aortic systolic blood pressure and maximal flow, as well as steeper aortic pressure and flow wave upstrokes. After TAVR, the forward wave pumped by the heart is enhanced. Although the arterial properties remain unchanged, the central augmentation index (AIx) is markedly decreased after TAVR. This challenges the interpretation of AIx as a solely vascular measure in patients with aortic valve stenosis.

Pathophysiology of the aortic regurgitation Doppler signal end-diastolic notching: "A-dip insight".

A 76-year-old man was admitted to the hospital with symptoms of severe decompensated heart failure. Initial echocardiogram showed normal left ventricular (LV) ejection fraction, grade II diastolic dysfunction, and mild-to-moderate aortic regurgitation. The aortic regurgitant Doppler signal exhibited an end-diastolic notching, called an A-dip. After intravenous diuretic therapy and 3 kg weight loss, a new echocardiogram was performed showing a grade I diastolic dysfunction and complete abolishment of the A-dip. Aortic A-dip is a rare finding denoting increased LV filling pressures. Conditions that favor its occurrence are increased LV stiffness, low diastolic blood pressure, and preserved left atrial contractility.

3D-printed heart model to guide LAA closure: useful in clinical practice?

OBJECTIVES: Correct device sizing for left atrial appendage (LAA) closure remains challenging due to complex LAA shapes. The aim of our study was to investigative the utility of personalized 3D-printed models (P3DPM) of the LAA to guide device size selection. METHODS: Fifteen patients (75.4 ±8.5years) scheduled for LAA closure using an Amulet device underwent cardiac computed tomography (CT). The LAA was segmented by semiautomatic algorithms using Vitrea® software. A 1.5-mm LAA thick shell was exported in stereolithography format and printed using TangoPlus flexible material. Different Amulet device sizes on the P3DPM were tested. New P3DPM-CT with the device was acquired in order to appreciate the proximal disc sealing the LAA ostium and the compression of the distal lobe within the LAA. We predicted the device size with P3DPM and compared this with the device sizes predicted by transesophageal echocardiography (TEE) and CT as well as the device size implanted in patients. RESULTS: The device size predicted by 3D-TEE and CT corresponded to the implanted device size in 8/15 (53%) and 10/15 (67%), respectively. The predicted device size from the P3DPM was accurate in all patients, obtaining perfect contact with the LAA wall, without device instability or excessive compression. P3DPM-CT with the deployed device showed device deformation and positioning of the disk in relation to the pulmonary veins, allowing us to determine the best device size in all 15 cases. CONCLUSION: P3DPM allowed us to simulate the LAA closure procedure and thus helped to identify the best Amulet size and position within the LAA. KEY POINTS: • A 3D-printed heart model allows to simulate the LAA closure procedure. • A 3D-printed heart model allowed to identify the optimal Amulet size and position. • 3D-printed heart models may contribute to reduce the Amulet implantation learning curve.

[Role of echocardiography before, during and after anticancer treatment]. / Rôle de l'échocardiographie avant, pendant et après un traitement anticancéreux.

Cardiologists increasingly must face not only the cardiotoxicity of certain cancer therapies, but also the burden of morbidity related to previous chemotherapy in cancer survivors. Due to the formidable effectiveness of novel oncology treatments, cancer patients are treated with drugs with limited experience of their use and systemic toxicity profile, notably their cardiotoxic effects. Echocardiography is recognized as a must in the evaluation of patients before, during and after their potentially cardiotoxic treatment. We discuss how certain echocardiographic parameters, including the evaluation of left ventricular ejection fraction but also other factors that can help guide the management of cancer patients throughout their treatment and beyond.

Avec l'amélioration générale du pronostic des cancers, les cardiologues sont de plus en plus confrontés non seulement à la cardiotoxicité immédiate de certaines thérapies oncologiques, mais également à la survenue de complications tardives chez les patients en rémission. Devant l'efficacité redoutable de certaines nouvelles thérapies, les patients bénéficient souvent précocement de molécules pour lesquelles nous manquons de recul quant à leur toxicité potentielle systémique et cardiaque. L'échocardiographie est actuellement reconnue comme un moyen incontournable dans l'évaluation avant, pendant et après un traitement potentiellement cardiotoxique. Nous discutons dans cet article des paramètres échocardiographiques, incluant l'évaluation de la fraction d'éjection du ventricule gauche, mais aussi d'autres facteurs qui peuvent aider à orienter la prise en charge des patients oncologiques tout au long de leur traitement.

[Mitral clipping in the treatment of secondary mitral regurgitation]. / Clip mitral dans l'insuffisance mitrale secondaire.

Secondary mitral regurgitation is a frequent valvulopathy due to left ventricle remodeling. Although, its poor prognostic has been established, surgical interventions have shown no substantial benefits in terms of mortality benefit. MitraClip represents a transcatheter alternative. Two randomized trials - MITRA-FR and COAPT comparing the clipping versus optimal medical therapy- have confirmed the feasibility of this intervention in patients with secondary mitral regurgitation. MITRA-FR did not show any significant benefit for the MitraClip group with respect to the composite endpoint (all-cause mortality and rehospitalization for heart failure) at 12 months. On the other hand, COAPT showed a clear superiority of MitraClip in terms of mortality and rehospitalization rates, compared to the conservative treatment alone at 24 months.

L'insuffisance mitrale secondaire est une pathologie fréquente dont la prise en charge médicale est primordiale. L'approche chirurgicale n'a pas montré de bénéfice significatif en termes de réduction de la mortalité. Récemment, les procédures d'implantation de clips mitraux ont été analysées au cours de deux études randomisées (MITRA-FR et COAPT) qui comparent le clip à un traitement médicamenteux optimal. MITRA-FR n'a pas montré de bénéfice du clip par rapport au traitement médicamenteux pour le critère de jugement primaire (mortalité de toute cause et réhospitalisation pour insuffisance cardiaque) à 12 mois. A l'opposé, l'étude COAPT a montré un clair bénéfice du MitraClip par rapport au traitement conservateur en termes de mortalité globale et réhospitalisation pour insuffisance cardiaque à 24 mois.

Comorbidities and Subgroups of Patients Surviving Severe Acute Hypercapnic Respiratory Failure in the Intensive Care Unit.

RATIONALE: No methodical assessment of the lung, cardiac, and sleep function of patients surviving an acute hypercapnic respiratory failure episode requiring admission to the intensive care unit (ICU) has been reported in the literature. OBJECTIVES: To prospectively investigate the prevalence and impact of comorbidities in patients treated by mechanical ventilator support (invasive or noninvasive) for acute hypercapnic respiratory failure in the ICU. METHODS: Seventy-eight consecutive patients admitted for an episode of acute hypercapnic respiratory failure underwent an assessment of lung, cardiac, and sleep function by pulmonary function tests, transthoracic echocardiography, and polysomnography 3 months after ICU discharge. MEASUREMENTS AND MAIN RESULTS: Sixty-seven percent (52 of 78) of patients exhibited chronic obstructive pulmonary disease (COPD), although only 19 had been previously diagnosed. Patients without COPD were primarily obese. Prevalence of severe obstructive sleep apnea was 51% (95% confidence interval, 34-69) in patients with COPD and 81% (95% confidence interval, 54-96) in patients without COPD. Previously undiagnosed cardiac dysfunction with preserved ejection fraction was highly prevalent (44%), as was hypertension (67%). More than half of the population demonstrated at least three major comorbidities known to precipitate acute hypercapnic respiratory failure. Multimorbidity was associated with longer time to hospital discharge. Hospital readmission or death occurred in 46% of patients over an average of 3.5 months after discharge. CONCLUSIONS: Severe hypercapnic respiratory failure requiring ICU admission resulted primarily from COPD or obesity. Major comorbidities are highly prevalent in both cases and most often ignored. Surviving acute hypercapnic respiratory failure should be an opportunity to systematically evaluate lung, heart, and sleep functions to improve poor outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT 02111876).

[Patent foramen ovale closure : update]. / Fermeture du foramen ovale perméable : où en sommes-nous en 2018 ?

The question of whether to perform percutaneous PFO closure to reduce the risk of recurrent ischemic stroke has been a dilemma for many years. Recent randomized trials have shown the superiority of percutaneous closure compared to medical therapy for large shunts. The indication of PFO closure is based on a multidisciplinary decision involving neurologists, cardiologists and hemostasis specialists. Important points are: PFO anatomy, brain imaging, history of venous thromboembolism and potential thrombophilia. In addition, atrial fibrillation (AF) should systematically be excluded. The intervention is performed under fluoroscopic guidance alone or with additional echocardiographic guidance. The procedural complication rate is low. There is an increased incidence of AF after percutaneous closure compared with medical therapy.

De récentes données randomisées démontrent une supériorité de la fermeture percutanée du foramen ovale perméable (FOP) comparée au traitement médicamenteux lors de shunt de grande taille. La fermeture du FOP repose sur une décision multidisciplinaire lors d'un colloque entre neurologues, cardiologues et spécialistes de l'hémostase. Les points à considérer sont : l'anatomie du FOP, l'imagerie cérébrale, les antécédents de maladie thromboembolique veineuse et la recherche d'une thrombophilie. De plus, il faut systématiquement exclure la fibrillation auriculaire (FA). L'intervention se fait par un accès veineux fémoral sous guidance fluoroscopique seul ou avec également une guidance échocardiographique. Le taux de complications lors de la procédure est faible mais il existe une augmentation de l'incidence de FA après fermeture percutanée.

Multimodality imaging evaluation of a mitro-aortic fibrosa pseudoaneurysm fistulizing into both atria.

To our knowledge, we describe the first case of a pseudoaneurysm of the mitro-aortic intervalvular fibrosa fistulizing into both atria, following an aortic bacterial endocarditis and valve replacement.

RIght VErsus Left Apical transvenous pacing for bradycardia: Results of the RIVELA randomized study.

AIMS: To compare cardiac function when pacing from the right or left ventricular apex in patients with preserved left ventricular systolic function, at 1-year follow-up. METHODS: Prospective, multicentre centre randomizing conventional right ventricular apical (RVA) versus left ventricular apical (LVA) pacing using a coronary sinus lead in patients requiring ventricular pacing for bradycardia. Follow-up was performed using 3D-echocardiography at 6 and 12 months. RESULTS: A total of 36 patients (age 75.4 ± 8.7 years, 21 males) were enrolled (17 patients in the RVA group and 19 patients in the LVA group). A right ventricular lead was implanted in 8 patients in the LVA group, mainly because of high capture thresholds. There were no differences in the primary endpoint of LVEF at 1 year (60.4 ± 7.1% vs 62.1 ± 7.2% for the RVA and LVA groups respectively, P = 0.26) nor in any of the secondary endpoints (left ventricular dimensions, left ventricular diastolic function, right ventricular systolic function and tricuspid/mitral insufficiency). LVEF did not change significantly over follow-up in either group. Capture thresholds were significantly higher in the LVA group, and two patients had unexpected loss of capture of the coronary sinus lead during follow-up. CONCLUSIONS: Left univentricular pacing seems to be comparable to conventional RVA pacing in terms of ventricular function at up to 1 year follow-up, and is an option to consider in selected patients (e.g. those with a tricuspid valve prosthesis).

[Discovery of left ventricular hypertrophy during adult echocardiography]. / Découverte d'une hypertrophie ventriculaire gauche à l'échocardiographie adulte.

Left ventricular hypertrophy is a common finding during echocardiography. A precise evaluation of the left ventricular wall thickness, ventricular mass and distribution of hypertrophy is crucial both for diagnostic workup, follow-up and for prognostic evaluation. The differential diagnosis of left ventricular hypertrophy includes hypertrophic cardiomyopathies, hypertrophy secondary to abnormal left ventricular filling conditions, hypertrophy linked to intense physical training and the isolated basal septal hypertrophy of the elderly. Amongst the tools at the disposition of the cardiologist, regional analysis of longitudinal strain appears promising in helping distinguish cardiac amyloidosis form other forms of hypertrophy.

La découverte d'une hypertrophie ventriculaire gauche est fréquente en échocardiographie. Une évaluation précise de l'épaisseur des parois, de la masse myocardique et de la répartition de l'hypertrophie est essentielle dans le cadre de la démarche diagnostique, du suivi et dans l'évaluation du pronostic. Le diagnostic différentiel de l'hypertrophie ventriculaire gauche comprend les cardiomyopathies hypertrophiques, l'hypertrophie secondaire à des conditions de charge anormales, les modifications liées à l'entraînement sportif intense et le bourrelet basoseptal de la personne âgée. Parmi les outils à disposition du cardiologue, l'analyse régionale du « strain ¼ longitudinal a montré des résultats prometteurs pour aider à distinguer l'amyloïdose cardiaque des autres formes d'hypertrophie ventriculaire gauche.

[Post-myocardial infarction ventricular septal defect]. / Communication interventriculaire postinfarctus du myocarde : mise au point.

Post-myocardial infarction ventricular septal defect corresponds to the rupture of the ventricular septum between the healthy and infarcted parts. It is a rare complication still associated with a high mortality rate. Its diagnostic should be evoked in case of pathologic cardiac auscultation and confirmed by emergent transthoracic echocardiography. Hemodynamic stabilisation, mainly with the insertion of an intra-aortic balloon pump is the first step in the management. The subsequent modality of closure, either surgical or transcatheter, as well as the ideal timing should be discussed in the Heart team. Successful closure decreases the 30-day mortality rate to 30-40 %.

La communication interventriculaire postinfarctus du myocarde correspond à la rupture du septum interventriculaire au niveau de la transition entre les tissus sain et infarci. C'est une complication rare mais mortelle après un infarctus du myocarde. Le diagnostic est avant tout clinique et doit être évoqué en cas d'auscultation cardiaque pathologique et confirmé par une échocardiographie transthoracique réalisée en urgence. La stabilisation hémodynamique, dans la majorité des cas à l'aide d'un ballon de contre-pulsion intra-aortique, est la première étape de la prise en charge. Ensuite, la décision d'une fermeture chirurgicale ou percutanée et son timing doivent être évalués au sein du Heart team. La fermeture chirurgicale ou percutanée permet de diminuer la mortalité à 30-40 % à 30 jours.

The LUCAS 2 chest compression device is not always efficient: an echographic confirmation.

Survival after cardiac arrest depends on prompt and effective cardiopulmonary resuscitation (CPR). Resuscitative teams are more frequently using mechanical chest compression devices, as documented in physiologic and experimental data, suggesting that these devices are more effective than manual CPR. A 41-year-old male patient presented with an ST-elevation myocardial infarction with cardiac arrest. The patient was immediately resuscitated by manual chest compressions; CPR was continued with a mechanical chest compression device (LUCAS 2). The patient had experienced a 15-minute period of "low-flow" without "no-flow" episode. After a discussion with the heart team, we decided that the patient was a candidate for extracorporeal membrane oxygenation (ECMO) therapy. During the ECMO implantation, we noticed that while performing transesophageal echocardiography, chest compressions were ineffective with the machine. After the ECMO implantation, we observed myocardial damage in the right-sided heart cavities. The present case report illustrates the likelihood that the mechanical chest compression device has limitations that might contribute to inadequate CPR. Therefore, rescuers should consider the efficacy of their chest compression through a continuous hemodynamic monitoring during CPR.

An interesting case of tricuspid aortic valve with a quadricuspid function.

Quadricuspid aortic valve (QAV) is a rare congenital heart defect, often related to severe aortic regurgitation, and usually detected by echocardiography or at the time of aortic valve surgery. We report a case of an interesting and extremely rare variant of "false" QAV, detected preoperatively by transthoracic and transesophageal echocardiography, in a severely symptomatic patient, admitted to our hospital for dyspnea. Three leaflets of aortic valve appeared quadricuspid, because the left coronary cusp was divided into 2 parts, as confirmed by MRI and pathology. Most frequently, QAV presents with all 4 leaflets equal in size.

Measurement of left and right atrial volume in patients undergoing ablation for atrial arrhythmias: comparison of a manual versus semiautomatic algorithm of real time 3D echocardiography.

AIMS: Real time full-volume 3D echocardiography (3DE) allows rapid and noninvasive measurement of left (LA) and right atrial (RA) volume without geometric assumptions. Different algorithms from different commercial providers are available. Older software requires manual tracing of endocardial contours. Recently, software with semiautomatic endocardial contour-finding algorithms has become available, which considerably speeds up the procedure. Our aim was to compare, in the same dataset, both LA and RA volumes determined by an algorithm involving manual tracing to the corresponding volumes obtained by an algorithm with semiautomatic contour detection. METHODS: Maximal atrial volumes were measured in 88 patients using a multiplane interpolation method algorithm based on manual planimetry of 8 slices. These volumes were compared with volumes determined by the QLAB 8.1 software using semiautomatic border detection. RESULTS: Linear regression showed excellent correlation between volumes determined by manual and by semiautomatic software for both LA and RA (r(2) = 0.90 and 0.89, respectively, P < 0.001). Bland-Altman analysis of manual versus semiautomatic volume determination showed narrow 95% limits of agreement (-15.9 to +12.0 mL for LA volume and -13.9 to +12.2 mL for RA volume) with a minimal bias of -1.9 ± 7.0 mL and -0.8 ± 6.5 mL, respectively, by the semiautomatic method. CONCLUSION: The semiautomatic border detection method shows excellent correlation for maximal LA and RA volume determination compared to the more time-consuming, multiplane interpolation method, with only slight underestimation. The results indicate that values of LA and RA volumes obtained by either algorithm can be compared, for example, during follow-up examinations.

Transient symptomatic severe mitral regurgitation after electric cardioversion of atrial fibrillation.

INTRODUCTION: After electric cardioversion (EC), several cases of cardiac stunning with cardiogenic shock have been reported. Several hypotheses have been proposed, including stunning of the left ventricle (LV) and modifications in the LV conformation that could lead to severe mitral regurgitation (MR). We report 2 cases of cardiogenic shock with severe MR after EC for atrial fibrillation (AF). CASE 1: A 75-year-old man presented with AF. A transesophageal echocardiography before the EC showed moderate MR. Shortly after successful EC, the patient developed a cardiogenic shock. The transthoracic and a transesophageal echocardiography showed severe MR. Four days later, an echocardiography showed recovery of MR to a moderate grade. CASE 2: An 85-year-old woman with a history of percutaneous aortic valve replacement presented with AF. After EC, she developed a cardiogenic shock. The transthoracic echocardiography showed severe MR. After recovery, the echocardiography showed moderate MR. DISCUSSION: Cardiac stunning after EC is well known and could explain the development of severe MR due to restrictive movement of leaflets. The transient character of the MR favors a functional origin with an alteration in the geometry of the mitral apparatus. Some cases of so-called "eclipsed MR" are described in the literature, however, independently to electric shocks. CONCLUSION: In some patients, flash pulmonary edema seems to be due to transient severe functional MR, although the exact underlying physiopathologic mechanism remains unclear. An ischemic origin with papillary muscle dysfunction due to transient low perfusion could also be advocated.

Case Report: Right atrial mass arising from the Eustachian valve.

A mass in the right atrium (RA) is an unusual finding that warrants further investigation. We report the case of a 72-year-old male patient who underwent a Bentall operation with a biological composite graft and closure of patent foramen ovale 18 months prior to his presentation with an incidental new RA mass during follow-up echocardiography. Transesophageal echocardiography and thoracic CT angiography confirmed a right atrial mass attached to the Eustachian valve and additionally revealed a non-occlusive pulmonary embolism in the inferior lobar artery of the left lung. Despite 2 months of anticoagulation treatment, the size of the mass did not decrease. Further MRI imaging showed a central mass enhancement which raised concerns about a tumoral lesion. Following a discussion with the local Heart Team, management with surgical treatment was decided. The intraoperative findings revealed a 2.5 cm × 2.1 cm mass arising from the Eustachian valve and a non-diagnosed Chiari network in the RA. Both were resected and sent for a frozen section procedure which excluded a malignancy. The final histopathological analysis described fibrotic tissues compatible with an organized thrombus. The patient was discharged on postoperative day 7 without any complications. Although imaging studies are useful for the initial and differential diagnosis of RA masses, it is not always possible to get the final diagnosis without surgery. In case of a suspicion of a potentially malignant pathology, surgical exploration and resection are necessary.

The Impact of Left Ventricular Performance and Afterload on the Evaluation of Aortic Valve Stenosis: A 1D Mathematical Modeling Approach.

The transaortic valvular pressure gradient (TPG) plays a central role in decision-making for patients suffering from severe aortic stenosis. However, the flow-dependence nature of the TPG makes the diagnosis of aortic stenosis challenging since the markers of cardiac performance and afterload present high physiological interdependence and thus, isolated effects cannot be measured directly in vivo. We used a validated 1D mathematical model of the cardiovascular system, coupled with a model of aortic stenosis, to assess and quantify the independent effect of the main left ventricular performance parameters (end-systolic (Ees) and end-diastolic (Eed) elastance) and principal afterload indices (total vascular resistance (TVR) and total arterial compliance (TAC)) on the TPG for different levels of aortic stenosis. In patients with critical aortic stenosis (aortic valve area (AVA) ≤ 0.6 cm2), a 10% increase of Eed from the baseline value was associated with the most important effect on the TPG (-5.6 ± 0.5 mmHg, p < 0.001), followed by a similar increase of Ees (3.4 ± 0.1 mmHg, p < 0.001), in TAC (1.3 ±0.2 mmHg, p < 0.001) and TVR (-0.7 ± 0.04 mmHg, p < 0.001). The interdependence of the TPG left ventricular performance and afterload indices become stronger with increased aortic stenosis severity. Disregarding their effects may lead to an underestimation of stenosis severity and a potential delay in therapeutic intervention. Therefore, a comprehensive evaluation of left ventricular function and afterload should be performed, especially in cases of diagnostic challenge, since it may offer the pathophysiological mechanism that explains the mismatch between aortic severity and the TPG.

Renal dysfunction and outcome in left ventricular non-compaction.

BACKGROUND: While renal function has been observed to inversely correlate with clinical outcome in other cardiomyopathies, its prognostic significance in patients with left ventricular non-compaction cardiomyopathy (LVNC) has not been investigated. The aim of this study was to determine the prognostic value of renal function in LVNC patients. METHODS: Patients with isolated LVNC as diagnosed by echocardiography and/or magnetic resonance imaging in 4 Swiss centers were retrospectively analyzed for this study. Values for creatinine, urea, and estimated glomerular filtration rate (eGFR) as assessed by the CKD-EPI 2009 formula were collected and analyzed by a Cox regression model for the occurrence of a composite endpoint (death or heart transplantation). RESULTS: During the median observation period of 7.4 years 23 patients reached the endpoint. The ageand gender-corrected hazard ratios (HR) for death or heart transplantation were: 1.9 (95% confidence interval [CI] 1.4-2.6) for each increase over baseline creatinine level of 30 µmol/L (p < 0.001), 1.6 (95% CI 1.2-2.2) for each increase over baseline urea level of 5 mmol/L (p = 0.004), and 3.6 (95% CI 1.9-6.9) for each decrease below baseline eGFR level of 30 mL/min (p ≤ 0.001). The HR (log2) for every doubling of creatinine was 7.7 (95% CI 3-19.8; p < 0.001), for every doubling of urea 2.5 (95% CI 1.5-4.3; p < 0.001), and for every bisection of eGFR 5.3 (95% CI 2.4-11.6; p < 0.001). CONCLUSIONS: This study provides evidence that in patients with LVNC impairment in renal function is associated with an increased risk of death and heart transplantation suggesting that kidney function assessment should be standard in risk assessment of LVNC patients.