A new integrative approach combining right heart catheterization and echocardiography to stage aortic stenosis-related cardiac damage.

Introduction: Although staging of the extent of aortic stenosis (AS)-related cardiac damages is usually performed via echocardiography, this technique has considerable limitations in assessing pulmonary artery and right chamber pressures. The present hypothesis-generating study sought to explore the efficacy of a staging system of cardiac damage based on echocardiographic and invasive [right heart catheterization (RHC)] hemodynamic parameters in patients undergoing transcatheter aortic valve implantation (TAVI). Methods: We studied 90 symptomatic patients with severe AS in whom echocardiographic and invasive evaluation by RHC was obtained prior to TAVI. Cardiac damage stages were defined as follows: no cardiac damage (stage 0), left ventricular (LV) damage (stage 1), left atrial or mitral valve damage (stage 2), pulmonary vasculature or tricuspid valve damage (stage 3), and right ventricular (RV) dysfunction or low-flow state (stage 4). With the integrative approach using RHC, pulmonary hypertension (PH) was defined as an mPAP ≥25 mmHg and the low-flow state corresponded to a cardiac index of <1.8 L/min/m2 and a right atrial pressure of >10 mmHg. Results: During follow-up (median: 2.9 years), 43 patients (47.8%) died. The integrative cardiac damage staging was associated with a significant increase in all-cause and cardiovascular mortality per each increase of cardiac damage stage, whereas the outcome was similar according to the echocardiographic staging. Conclusions: A staging system of cardiac lesion based on echocardiographic and invasive hemodynamic parameters in patients with severe AS undergoing TAVI predicts mortality. Patients with pre-existing PH, ≥ moderate tricuspid regurgitation and/or RV dysfunction, and a low-flow state had a markedly increased risk of death. Further larger studies are needed to validate our findings.

Sparse holographic imaging for an integrated augmented reality near-eye display.

Diffraction is the main physical effect involved in the imaging process of holographic displays. In the application of near-eye displays, it generates physical limits that constrain the field of view of the devices. In this contribution, we evaluate experimentally an alternative approach for a holographic display based mainly on refraction. This unconventional imaging process, based on sparse aperture imaging, could lead to integrated near-eye displays through retinal projection, with a larger field of view. We introduce for this evaluation an in-house holographic printer that allows the recording of holographic pixel distributions at a microscopic scale. We show how these microholograms can encode angular information that overcomes the diffraction limit and could alleviate the space bandwidth constraint usually associated with conventional display design.

Can an Eight-Session Multicomponent Physical Exercise Program Reduce Fall Risk and Fear of Falling among the Elderly?

In older populations, falls are responsible for decrease autonomy and increased pain and injuries. With aging, fall risk is multifactorial and associated with sarcopenia, impaired balance, falls themselves and psychological factors such as fear of falling. The objectives of the present study were: (a) to test the effects of a short multicomponent physical exercise program on fall risk and fear of falling; and (b) to analyze the relationship between fall risk and fear of falling. The participants were thirty-five older persons who were engaged in an eight-session physical exercise program. Balance (i.e., One-leg Balance Test, and Functional Reach Test), lower-limb endurance (i.e., Wall-sit Test) and fear of falling were measured before and after the multicomponent physical exercise program. Results indicated an increase in balance and a diminution of fear of falling after the end of the physical exercise program (p < 0.05). The program has an effect on lower limb endurance (p > 0.05). Gains in balance were correlated to the diminution of fear of falling (p < 0.05). An 8-week multicomponent physical exercise program based on balance is efficient to reduce fall risk and fear of falling among the elderly.

Multi-user volumetric 360° display based on retro-reflective transparent surfaces.

We present in details the development of a 360° volumetric display based on the use of a transparent projection surface. The optical scheme derives from the Pepper's ghost configuration, known as holographic display. Our optical system requires high angular diffusion efficiency and an innovative transparent retro-reflective surface has been developed for that purpose. This surface is made of sparse cube corner distribution and we give some elements of its design and characterization. We describe also the optical design of the 360° display and gave the feedback of its presentation to the public during a symposium.

[Pilot study on the effects of an adapted physical activity program focused on the quality of life and risk indicators for falls in independent dwelling-women over 65 years]. / Étude pilote portant sur les effets d'un programme d'activités physiques adaptées sur la qualité de vie et les indicateurs du risque de chute chez des femmes autonomes âgées de plus de 65 ans.

Falls can have multiple detrimental consequences in the elderly, and this is particularly relevant for women. To prevent the risk of falling, intervention programmes based on physical exercises focusing on balance appear to be the most efficient, which explains the multiplication of this type of action at the local level. However, these actions are very rarely evaluated. METHODS: Our sample consists of 26 women (75.0 ± 6.7 years old), randomly assigned to two groups: an intervention group (GI) that has benefited from a balance-oriented adapted physical activity (APA) program focused on balance and conducted in an associative structure; and a control group (GC). Our study aims to evaluate different parameters such as physical (functional mobility, balance), subjective (balanced confidence) and health (quality of life) indicators in women over 65 years of age, living independently at home. RESULTS: In people completing the program, we observed an improvement in equilibrium capabilities (significant increase in POMA score; p < 0.05), in balance and functional mobility (significant decrease in TUG score; p < 0.01) and in balance confidence (significant increase in ABC-S; p < 0.05). CONCLUSION: The implementation of a short programme by the associative structure seems to be an interesting approach for the prevention of falls in autonomous elderly women.

Clinical significance of electrocardiographic markers of myocardial damage prior to aortic valve replacement.

BACKGROUND: Pre-operative myocardial fibrosis and remodeling impact on outcomes after aortic valve replacement (AVR). We aimed at investigating the prognostic impact of preoperative electrocardiographic (ECG) markers of left ventricular (LV) myocardial damage, i.e. bundle branch block (BBB) and ECG strain pattern after (surgical or transcatheter) AVR for severe aortic stenosis (AS). METHODS: Between April 2008 and October 2017, we explored consecutive patients referred to our Heart Valve Clinic for first AVR for severe AS. Detailed pre-operative phenotyping and ECG analysis were performed. Patients were followed-up after AVR for major cardiac events (ME), i.e. cardiovascular death, cardiac hospitalization for acute heart failure and stroke. RESULTS: BBB and ECG strain were respectively observed in 13.5 and 21% of the 1122 patients included. These ECG markers identified a subgroup of older patients, with higher NYHA class and more advanced myocardial disease as detected by echocardiography, i.e. higher LV mass and lower LV ejection fraction, global longitudinal strain and integrated backscatter, than patients without ECG strain or BBB. ME occurred in 212 (18.6%) patients during a mean follow-up of 4.4 ± 1.5 years with higher incidence in case of ECG strain or BBB (HR 1.56, 95%CI 1.13-2.14, p = 0.006; HR 1.47, 95%CI 1.02-2.13, p = 0.04 respectively). The prognostic value of ECG strain remained significant after adjustment for age, diabetes and pre-operative LVEF. CONCLUSIONS: Pre-operative ECG markers of myocardial damage identify a subgroup of AS patients at high risk of post-AVR cardiovascular complications irrespective of other prognostic factors and should help the multiparametric staging of cardiac damage to guide AVR.

Correlation between non-invasive myocardial work indices and main parameters of systolic and diastolic function: results from the EACVI NORRE study.

AIMS: The present study sought to evaluate the correlation between indices of non-invasive myocardial work (MW) and left ventricle (LV) size, traditional and advanced parameters of LV systolic and diastolic function by 2D echocardiography (2DE). METHODS AND RESULTS: A total of 226 (85 men, mean age: 45 ± 13 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. Global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE) were estimated from LV pressure-strain loops using custom software. Peak LV pressure was estimated non-invasively from brachial artery cuff pressure. LV size, parameters of systolic and diastolic function and ventricular-arterial coupling were measured by echocardiography. As advanced indices of myocardial performance, global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) were obtained. On multivariable analysis, GWI was significantly correlated with GLS (standardized beta-coefficient = -0.23, P < 0.001), ejection fraction (EF) (standardized beta-coefficient = 0.15, P = 0.02), systolic blood pressure (SBP) (standardized beta-coefficient = 0.56, P < 0.001) and GRS (standardized beta-coefficient = 0.19, P = 0.004), while GCW was correlated with GLS (standardized beta-coefficient = -0.55, P < 0.001), SBP (standardized beta-coefficient = 0.71, P < 0.001), GRS (standardized beta-coefficient = 0.11, P = 0.02), and GCS (standardized beta-coefficient = -0.10, P = 0.01). GWE was directly correlated with EF and inversely correlated with Tei index (standardized beta-coefficient = 0.18, P = 0.009 and standardized beta-coefficient = -0.20, P = 0.004, respectively), the opposite occurred for GWW (standardized beta-coefficient =--0.14, P = 0.03 and standardized beta-coefficient = 0.17, P = 0.01, respectively). CONCLUSION: The non-invasive MW indices show a good correlation with traditional 2DE parameters of myocardial systolic function and myocardial strain.

Impact of aortic stenosis on layer-specific longitudinal strain: relationship with symptoms and outcome.

AIMS: The present study sought to assess the impact of aortic stenosis (AS) on myocardial function as assessed by layer-specific longitudinal strain (LS) and its relationship with symptoms and outcome. METHODS AND RESULTS: We compared 211 patients (56% males, mean age 73 ± 12 years) with severe AS and left ventricular ejection fraction (LVEF) ≥50% (114 symptomatic, 97 asymptomatic) with 50 controls matched for age and sex. LS was assessed from endocardium, mid-myocardium, and epicardium by 2D speckle-tracking echocardiography. Despite similar LVEF, multilayer strain values were significantly lower in symptomatic patients, compared to asymptomatic and controls [global LS: 17.9 ± 3.4 vs. 19.1 ± 3.1 vs. 20.7 ± 2.1%; endocardial LS: 20.1 ± 4.9 vs. 21.7 ± 4.2 vs. 23.4 ± 2.5%; epicardial LS: 15.8 ± 3.1 vs. 16.8 ± 2.8 vs. 18.3 ± 1.8%; P < 0.001 for all]. On multivariable logistic regression analysis, endocardial LS was independently associated to symptoms (P = 0.012), together with indexed left atrial volume (P = 0.006) and LV concentric remodelling (P = 0.044). During a mean follow-up of 22 months, 33 patients died of a cardiovascular event. On multivariable Cox-regression analysis, age (P = 0.029), brain natriuretic peptide values (P = 0.003), LV mass index (P = 0.0065), LV end-systolic volume (P = 0.012), and endocardial LS (P = 0.0057) emerged as independently associated with cardiovascular death. The best endocardial LS values associated with outcome was 20.6% (sensitivity 70%, specificity 52%, area under the curve = 0.626, P = 0.022). Endocardial LS (19.1 ± 3.3 vs. 20.7 ± 3.3, P = 0.02) but not epicardial LS (15.2 ± 2.8 vs. 15.9 ± 2.5, P = 0.104) also predicted the outcome in patients who were initially asymptomatic. CONCLUSION: In patients with severe AS, LS impairment involves all myocardial layers and is more prominent in the advanced phases of the disease, when the symptoms occur. In this setting, the endocardial LS is independently associated with symptoms and patient outcome.

Global and regional myocardial function and outcomes after transcatheter aortic valve implantation for aortic stenosis and preserved ejection fraction.

AIM: To investigate the effects of transcatheter aortic valve implantation (TAVI) on early recovery of global and segmental myocardial function in patients with severe symptomatic aortic stenosis and preserved left ventricular ejection fraction (LVEF) and to determine if parameters of deformation correlate with outcomes. METHODS: The echocardiographic (strain analysis) and outcome (hospitalizations because of heart failure and mortality) data of 62 consecutive patients with preserved LVEF (64.54 ±â€Š7.97%) who underwent CoreValve prosthesis implantation were examined. RESULTS: Early after TAVI (5 ±â€Š3.9 days), no significant changes in LVEF or diastolic function were found, while a significant drop of systolic pulmonary artery pressure (PAP) occurred (42.3 ±â€Š14.9 vs. 38.1 ±â€Š13.9 mmHg, P = 0.028). After TAVI global longitudinal strain (GLS) did not change significantly, whereas significant improvement in global mid-level left ventricular (LV) radial strain (GRS) was found (-16.71 ±â€Š2.42 vs. -17.32 ±â€Š3.25%; P = 0.33; 16.57 ±â€Š6.6 vs. 19.48 ±â€Š5.97%, P = 0.018, respectively). Early significant recovery of longitudinal strain was found in basal lateral and anteroseptal segments (P = 0.038 and 0.048). Regional radial strain at the level of papillary muscles [P = 0.038 mid-lateral, P < 0.001 mid-anteroseptum (RSAS)] also improved. There was a significant LV mass index reduction in the late follow-up (152.42 ±â€Š53.21 vs. 136.24 ±â€Š56.67 g/m, P = 0.04). Mean follow-up period was 3.5 ±â€Š1.9 years. Parameters associated with worse outcomes in univariable analysis were RSAS pre-TAVI, LV end-diastolic diameter after TAVI, relative wall thickness, and mitral E and E/A after TAVI. CONCLUSION: Global and regional indices of myocardial function improved early after TAVI, suggesting the potential of myocardium to recover with a reduced risk for clinical deterioration.

Pulmonary Hypertension with Valvular Heart Disease: When to Treat the Valve Disease and When to Treat the Pulmonary Hypertension.

PURPOSE OF REVIEW: This article will review the current guidelines for therapeutic intervention in (pulmonary hypertension) PH related to left heart disease (PH-LHD). RECENT FINDINGS: The 6th World Symposium on Pulmonary Hypertension (WSPH) recommended that the mean pulmonary artery pressure (mPAP) should be lowered to 20 mmHg. In several randomized controlled trials performed in patients with PH-LHD, pulmonary arterial hypertension (PAH)-specific drug therapy demonstrated no evidence of beneficial effects. Furthermore, in the sildenafil for improving outcomes after valvular correction (SIOVAC) trial, the use of sildenafil in the context of PH post-valvular heart disease (VHD) intervention is associated with an increased risk of clinical deterioration and death. Therefore, medical therapy such as PAH-specific drugs is still not recommended in PH-LHD. The principle of PH-LHD therapy is the treatment of underlying VHD. It is crucial to undergo surgical intervention at an appropriate time prior the development of potentially irreversible PH. Stress echocardiography (SE) is helpful to define symptoms and can be useful to assess the systolic pulmonary artery pressure (SPAP) and stratify severity of VHD. This comprehensive review of the literature highlights the role of SE imaging to assess VHD and is needed for the asymptomatic patients with severe VHD or symptomatic patients with non-severe VHD in the context of PH-LHD. The focus of patient evaluation should be on identifying patients with significant underlying valvular heart disease and referring in a timely manner for VHD treatment per society guidelines as pharmacologic pulmonary vasodilator therapy for PH-LHD has not shown efficacy as seen in other forms of PH.

Experimental validation of self-focusing image formation for retinal projection display.

The augmented reality (AR) industry requires both aesthetic designs and high performances of AR devices. This complex dilemma challenges R&D groups from all over the world to improve existing systems or propose new, breakthrough designs. The unconventional concept of direct retinal projection display may be one. It is based on see-through holographic retinal projection, with the image being formed via the so-called self-focusing effect. In this paper, we describe an experimental validation of this self-focusing effect and introduce a possible approach of self-focusing performance evaluation. Experimental image formation capability is demonstrated and compared with simulation results. Main present limitations of the concept are discussed, such as pixel addressing design and image resolution/sharpness conflict.

Angioedema: a rare and sometimes delayed side effect of angiotensin-converting enzyme inhibitors.

The effects of angiotensin converting enzyme (ACE) inhibitors result from the inhibition of the ACE (kininase II) to ultimately influence both the renin-angiotensin system and the degradation of the bradykinin (BK) metabolism. ACE inhibitors block the degradation of BK and substance P by ACE. In addition, an active metabolite of BK (Des-Arg9-BK) is catalysed by kininase I and its degradation is controlled in part by the conversion enzyme. These molecules have been associated with increased plasma extravasation associated with ACE inhibitors. ACE inhibitors are the leading cause of drug-induced Angioedema (AE). Symptoms of AE mainly occur after the first month of treatment by ACE. However, very late onset cases, sometimes after several years of stable therapy, are also described in the literature. It has been observed that patients previously stable under ACE inhibitor will most likely develop AE soon after the addition of another medication, including the combination of aspirin or non-steroid anti-inflammatory drugs with ACE inhibitor which has proved to be the most common cause, accounting for close to 50% of all AE cases related to ACE inhibitors. This side effect of ACE inhibitors, sometimes very late and rare, deserves to be recalled.

Coronary chronic total occlusion intervention: utility or futility.

INTRODUCTION: Despite an incidence of about 18-52% of the patients undergoing coronary angiography, chronic total occlusions (CTO) are rarely revascularised by percutaneous angioplasty (PCI). Nevertheless, current evidence suggests that successful CTO angioplasty improves symptoms, quality of life and long-term survival. During the last decade, the improvement of specific tools and techniques for these complex procedures, and the increasing experience of operators, have led to the achievement of success and complication rates almost equivalent to non-CTO angioplasty. Areas covered: This review focuses on the clinical benefits of CTO revascularization and on appropriate patient selection. Expert commentary: Current evidence suggests that successful CTO-PCI improves symptoms, quality of life and long-term survival. During the last years, the improvement of specific techniques for these complex procedures and the increasing experience of operators, have led to the achievement of success and complication rates almost equivalent to non-CTO lesion angioplasty.

[Why to treat a total chronic coronary occlusion?] / Pourquoi traiter une occlusion coronaire totale chronique ?

Despite an incidence of about 15% of the patients undergoing coronary angiography, total chronic occlusions (CTO) are rarely revascularized by percutaneous angioplasty (PCI). Nevertheless, current evidence suggest that successful CTO-PCI improve symptoms, quality of live and long-term survival. During the last years, improvement of specific techniques for these complexes procedures and increasing experience of operators allow actually to obtain success and complications rates almost equivalent to non-CTO lesions angioplasty. This review focus on the clinical benefits of CTO revascularization and on appropriate patient selection.

Bien que présentes chez environ 15% des patients admis pour une coronarographie diagnostique, les occlusions coronaires totales chroniques (CTO) sont très rarement revascularisées par angioplastie percutanée. Pourtant, de nombreux éléments suggèrent que la revascularisation percutanée d'une CTO est associée à une amélioration des symptômes angineux, de la qualité de vie et de la survie à long terme. Ces dernières années, l'amélioration des techniques dédiées à ces procédures complexes et l'expérience croissante des opérateurs ont permis d'obtenir des taux de succès et de complications qui approchent ceux des lésions coronaires non-CTO. Cet article fait le point sur les principaux bénéfices de traiter une CTO et sur la sélection appropriée des patients.

Echo-Doppler estimation of left ventricular filling pressure: results of the multicentre EACVI Euro-Filling study.

AIMS: The present Euro-Filling report aimed at comparing the diagnostic accuracy of the 2009 and 2016 echocardiographic grading algorithms for predicting invasively measured left ventricular filling pressure (LVFP). METHOD AND RESULTS: A total of 159 patients who underwent simultaneous evaluation of echo estimates of LVFP and invasive measurements of LV end-diastolic pressure (LVEDP) were enrolled at nine EACVI centres. Thirty-nine (25%) patients had a reduced LV ejection fraction (<50%), 77 (64%) were in NYHA ≥ II, and 85 (53%) had coronary artery disease. Sixty-four (40%) patients had elevated LVEDP (≥15 mmHg). Taken individually, all echocardiographic Doppler estimates of LVFP (E/A, E/e', left atrial volume, tricuspid regurgitation jet velocity) were marginally correlated with LVEDP. By using the 2016 recommendations, 65% of patients with normal non-invasive estimate of LVFP had normal LVEDP, while 79% of those with elevated non-invasive LVFP had elevated invasive LVEDP. By using 2009 recommendations, 68% of the patients with normal non-invasive LVFP had normal LVEDP, while 55% of those with elevated non-invasive LVFP had elevated LVEDP. The 2016 recommendations (sensitivity 75%, specificity 74%, positive predictive value 39%, negative predictive value 93%, AUC 0.78) identified slightly better patients with elevated invasive LVEDP (≥ 15 mmHg) as compared with the 2009 recommendations (sensitivity 43%, specificity 75%, positive predictive value 49%, negative predictive value 71%, AUC 0.68). CONCLUSION: The present Euro-Filling study demonstrates that the new 2016 recommendations for assessing LVFP non-invasively are fairly reliable and clinically useful, as well as superior to the 2009 recommendations in estimating invasive LVEDP.

3D echocardiographic reference ranges for normal left ventricular volumes and strain: results from the EACVI NORRE study.

AIM: To obtain the normal ranges for 3D echocardiography (3DE) measurement of left ventricular (LV) volumes, function, and strain from a large group of healthy volunteers. METHODS AND RESULTS: A total of 440 (mean age: 45 ± 13 years) out of the 734 healthy subjects enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study had good-quality 3DE data sets that have been analysed with a vendor-independent software package allowing homogeneous measurements regardless of the echocardiographic machine used to acquire the data sets. Upper limits of LV end-diastolic and end-systolic volumes were larger in men (97 and 42 mL/m2) than in women (82 and 35 mL/m2; P < 0.0001). Conversely, lower limits of LV ejection fraction were higher in women than in men (51% vs. 50%; P < 0.01). Similarly, all strain components were higher in women than in men. Lower range was -18.6% in men and -19.5% in women for 3D longitudinal strain, -27.0% and -27.6% for 3D circumferential strain, -33.2% and -34.4% for 3D tangential strain and 38.8% and 40.7% for 3D radial strain, respectively. LV volumes decreased with age in both genders (P < 0.0001), whereas LV ejection fraction increased with age only in men. Among 3DE LV strain components, the only one, which did not change with age was longitudinal strain. CONCLUSION: The NORRE study provides applicable 3D echocardiographic reference ranges for LV function assessment. Our data highlight the importance of age- and gender-specific reference values for both LV volumes and strain.

Pulmonary Hypertension in Aortic Stenosis and Mitral Regurgitation: Rest and Exercise Echocardiography Significance.

Valvular heart disease is a common cause of increased mean pulmonary artery pressure (PAP). Aortic stenosis and mitral regurgitation are frequently accompanied by pulmonary hypertension (PH), especially when they are severe and symptomatic. In asymptomatic patients, PH is rare, though the exact prevalence is unknown and mainly stems from the severity of the valvular heart disease and the presence of diastolic dysfunction. Exercise echocardiography has recently gained interest in depicting PH. In these asymptomatic patients, exercise PH is observed in about >40%. Either PH at rest (systolic PAP >50 mmHg) or during exercise (systolic PAP >60 mmHg) is a powerful determinant of outcome and is independently associated with reduced survival, regardless of the severity of the underlying valvular pathology.