Predictors of mitral annulus enlargement? A real-time three-dimensional transesophageal study.

BACKGROUND: Mitral annulus (MA) enlargement can be observed in various cardiac conditions but respective influence of left atrial (LA) and left ventricle (LV) size remained unclear. METHODS: In 120 patients who underwent a clinically indicated 3D-transesophageal-echocardiography, 30 atrial fibrillation (AF), 30 secondary mitral regurgitation (SMR), 30 primary myxomatous mitral regurgitation (PMR) and 30 mitral stenosis (MS), we evaluated the association between MA area (MA-area) and LA volume (LAvol) measured using the biplane area-length method, end-diastolic (LVEDV) and end-systolic (LVESV) volumes measured using the biplane Simpson method. MA-area was measured based on 3D datasets using QLab10. RESULTS: MA-area was correlated to LVEDV (r = 0.42, p < 0.0001), LVESV (r = 0.29, p = 0.001) but more markedly to LAvol (r = 0.62, p < 0.0001). Correlation between MA-area and LAvol was sustained in all subsets whereas MA-area was not correlated to LVEDV and LVESV in patients with SMR and with PMR (all p > 0.10). In multivariate analysis main predictors of MA-area were LAvol (p < 0.0001) and myxomatous etiology of MR (p = 0.0003) followed by LVEDV (p = 0.006) and LVESV (p = 0.02). CONCLUSION: In a population of patients with a wide range of LA/LV size related to various conditions, LA volume and myxomatous MR etiology appeared as main predictors of MA size whereas LV size had a more modest influence.

Identifying the needs for competency-based education in Europe: a needs assessment of cardiologists across 52 countries.

Objective: This international needs assessment was mandated by the European Society of Cardiology (ESC) to obtain an in-depth understanding of the current gaps and challenges of European cardiology professionals, with the aim to provide evidence for the development of needs-driven educational and professional development activities. Methods: This ethics-approved needs assessment was conducted among cardiologists from all sub-specialties across 56 countries of Europe and the Mediterranean basin. A mixed-methods research approach was used, combining qualitative in-depth interviews and focus groups with a quantitative survey. Results: Seventy-four (74) cardiologists participated in the qualitative phase and 866 completed the survey. Respondents represented 52 of the 56 targeted countries. Three themes were identified: 1) Challenges in the clinical decision-making process, 2) Challenges in establishing the patient-physician relationship, and 3) Sub-optimal team communication and collaboration. Specific gaps and causalities related to each challenge were found. Although most of the gaps were common across countries and sub-specialties, some significant differences were noted. Conclusion: The findings of this needs assessment indicate gaps and challenges in clinical practice across countries and across sub-specialities. Taking cardiology as an example, this study identifies clear areas of focus, especially around issues of collaboration and communication, for targeted competency-based education in Europe.

Eclipsed mitral regurgitation: an unusual cause of acute heart failure.

AIMS: So far, a total of five patients with eclipsed mitral regurgitation (MR) have been reported in the literature by three different teams. The aim of this article was to detail clinical and echocardiographic characteristics, and outcome of patients presenting eclipsed MR. METHODS AND RESULTS: We defined eclipsed MR as spontaneous appearance, at rest, from 1 min to the next of an acute restriction in the motion of mitral leaflets preventing coaptation and leading to massive MR in patients with normal left ventricular end-diastolic diameter, left ventricular ejection fraction >45%, and baseline MR ≤2. Spontaneous regression occurred within 30 min, and no obvious trigger such as acute hypertension, new-onset arrhythmia, or myocardial ischaemia is present. Clinical data, ECG, echocardiographic data, surgery report, and follow-up status of six patients with eclipsed MR are reported: all were post-menopausal women with median age of 74 [57-80] years presenting hypertension (4/6), chronic kidney disease (5/6), or chronic anaemia (4/6). Five out of six patients experienced acute pulmonary oedema requiring hospitalization and underwent mitral valve replacement because of heart failure recurrence. Two patients died in the first days after surgery while the three others are free of symptoms at, respectively, 56, 18, and 10 months follow-up. CONCLUSION: Eclipsed MR is a clinical and echocardiographic syndrome responsible for heart failure with preserved EF. It is presently underdiagnosed and should be evoked in cases of recurrent acute pulmonary oedema without obvious trigger, in particular in patients presenting discordant evaluation of MR severity over time.

Mitral regurgitation. Timing of surgery or interventional treatment.

The treatment of mitral regurgitation has changed in recent years because of improvements in the surgical treatment, in particular valve repair, and the advent of interventional techniques, mainly percutaneous edge-to-edge repair. Regardless of the technique used, better results are obtained for interventions in primary mitral regurgitation than in secondary mitral regurgitation, which remains a challenge. Further developments are expected in the future thanks to a better understanding of the epidemiology and the mechanisms of secondary mitral regurgitation, the development of interventional techniques, and a careful evaluation.

Percutaneous aortic valve interventions in heart failure patients.

The onset of symptoms of heart failure is a landmark in the natural history of aortic stenosis, and is associated with a dramatic reduction in survival. Aortic valve replacement markedly increases life-expectancy in such patients. However, the presence of heart failure and/or left ventricular dysfunction are strong predictors of poor acute and late mortality after cardiac surgery and the most frequent conditions leading to deny surgical aortic valve replacement in elderly patients. The last decade has witnessed the development of transcatheter aortic valve implantation (TAVI) and, consequently, the resurgence of percutaneous balloon aortic valvuloplasty (PBAV) and, both, are currently routine therapy for high-risk patients. These minimally invasive procedures are appealing therapeutic options for the subset of patients with heart failure and or/left ventricular systolic dysfunction. The available evidence on the results of PBAV and TAVI therapies in this setting is discussed and a management strategy is proposed.

[Percutaneous approaches to mitral valve disease]. / Approches percutanées des valvulopathies mitrales.

Percutaneous approaches to mitral valve disease consist in modifications of existing surgical techniques, aiming to replicate the favourable outcomes of surgery, with less procedure-related risk, due to their less invasive nature. While some of these techniques are clearly indicated for the management of certain valve diseases, other appear as possible alternatives to surgery among patients deemed at high-risk or considered inoperable, or are still under clinical investigation. Major development of these percutaneous approaches is expected within the future, thus hopefully allowing treatment of a larger proportion of patients with mitral valve disease.

[Percutaneous exclusion of the left atrial appendage: perspectives]. / Exclusion percutanée de l'auricule gauche : perspectives.

With its high prevalence and well-known thromboembolic risk, atrial fibrillation (AF) is a crucial component of the 2010-2014 actions plan, ongoing in France to reduce the annual incidence of stroke. The stroke risk is stratified well with the CHA(2)DS(2)-VASc score. With the current guidelines, most patients with AF should be on oral anticoagulant regimen, a treatment recognized as effective but whose bleeding risks limit its use. In clinical practice, warfarin is often not prescribed in patients with high risk of stroke. Thus, the exploration of new ways in preventing thromboembolic events in patients with AF is needed. Beside new more convenient anticoagulant agents, the exclusion of the left atrial appendage recognized as main source of thrombi, may be an alternative in patients with both high risk of thrombotic and haemorrhagic events. Surgical experience showed that the results depend on the quality of the exclusion. For over the past 10 years, several percutaneous exclusion systems of the left atrial appendage have been developed. A randomized study (PROTECT AF) demonstrated the non-inferiority of the percutaneous exclusion in comparison with the warfarin. However, the place of this interventional therapy remains to be clarified, particularly the definition of the target population. This often multidisciplinary approach will have to be accompanied by a reduction of periprocedural complications, increase in rate of complete occlusion, and enough long clinical follow-up to assess the efficiency of this strategy.

[Transcutaneous aortic valve implantation: Anesthetic and perioperative management]. / Implantation valvulaire aortique percutanée: prise en charge par l'anesthésiste-réanimateur.

OBJECTIVE: To describe the perioperative management, from the point of view of the anesthesia-intensive care unit specialist, of patients with aortic stenosis who undergo transcatheter aortic valve implantation (femoral or apical TAVI). DATA SOURCE: The PubMed database (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) was queried, using the following keywords: aortic stenosis, transcatheter aortic valve implantation TAVI, outcome, complications, anesthesia. DATA SYNTHESIS: TAVI is performed in patients suffering from aortic stenosis and presenting with numerous comorbidities, high-predicted perioperative mortality and/or contraindications to conventional cardiac surgery. TAVI is performed either by percutaneous transfemoral or transapical puncture of the left ventricle (LV) apex. These patients are older, have more comorbidities than those undergoing aortic valve replacement surgery and perioperative mortality predicted by risk scores is higher. While transapical TAVI is performed with general anaesthesia, transfemoral TAVI can be performed with either general or locoregional anaesthesia and/or sedation. The choice of the anaesthetic technique for transfemoral TAVI depends on the patient's medical history, the technique chosen for valve implantation, the type of monitoring and the anticipated hemodynamic problems. The incidence of complications following TAVI is high, some are common to surgical aortic valve replacement, and others are specific to this technique. Because of the prevalence of comorbidities, the hemodynamic-specific constraints of this technique and the incidence of complications, anaesthetic and perioperative management (evaluation, anaesthetic technique, monitoring, post-surgery care) requires the same level of expertise as in cardiac surgery anaesthesia. CONCLUSION: TAVI expands treatment options for patients with aortic valve stenosis. The anaesthesia team must be involved in the care of these patients with the same level of expertise and care as in heart surgery on critical patients.

An unusual cause of pacemaker-induced severe tricuspid regurgitation.

Pacemaker (PM) induced tricuspid regurgitation (TR) is a common echocardiographic finding. Although mild or moderate TR is frequently observed, severe TR is rare. We report the exceptional observation of a severe TR due to leaflet malcoaptation occurring late after PM implantation and in the following weeks after an aortic valve replacement. Our hypothesis is that the aortic valve surgery has been responsible for conformational changes between cardiac cavities, tricuspid valve and PM leads resulting in a severe TR.

[Patent foramen ovale percutaneous closure: indications, techniques and results]. / Fermeture percutanée des foramens ovales perméables: indications, techniques et résultats.

A patent foramen ovale is almost physiological (15% of the population) but can be associated with some pathological situations in which its closure can be considered. The only medical indication currently accepted is a right-left shunt without elevation of the right pulmonary pressure, whose most famous pattern is the rare platypnea-orthodeoxie syndrome. PFO may be responsible for diving decompression accidents. Before taking the decision of closing a PFO, each situation must be discussed on a case to case basis. In spite of the possible link between some kinds of migraine and PFO, according to current knowledge, there is no evidence of the efficiency of PFO closure in this situation. The secondary prevention of a cryptogenic ischaemic cerebrovascular attack on a young person with a PFO associated to a membranous septum aneurysm, is the most commonly considered indication, but we lack valid data for this indication. The PFO closing procedure is well codified and its success rate is close to 100%, with rare major complications. Residual permeability within the prosthesis ensuring the closure of the PFO decreases gradually to get under 15% after six months. The clinical result is often dramatic when treating right-left shunts. As far as the secondary prevention of cryptogenic ischaemic cerebro vascular attacks in young people is concerned, there might be some clinical benefit, but we are waiting for the results of ongoing randomized and scheduled studies.

[Intracardiac echography]. / Echographie intracardiaque.

The role of echocardiography during non-coronary interventions is of increasing importance. They include percutaneous closure of atrial septal defects (ASD) or patent foramen ovale (PFO), percutaneous balloon mitral valvuloplasty (PMV), septal alcoholization, or interventional procedures managing arrhythmia. In all cases, echographic monitoring enables to guide the procedures, optimize and assess their results and avoid complications. This role could even increase with the development of other interventional techniques such as left auricle appendage exclusion or the percutaneous treatment of valvular diseases. This article reviews this new approach and its value in interventional cardiology.

[A pitfall of transseptal catheterisation for percutaneous mitral commissurotomy: interruption of the inferior vena cava with azygos continuation]. / Piège du cathétérisme transseptal pour commissurotomie mitrale percutanée: l'interruption de la veine cave inférieure avec continuation azygos. A propos d'un cas et revue de la littérature.

Transseptal catheterisation is a widely used technique in interventional cardiology. The authors report the case of a 37 year old woman admitted for percutaneous mitral commissurotomy of a symptomatic rheumatic mitral stenosis in whom transseptal catheterisation was impossible because of a rare congenital anomaly: interruption of the inferior vena cava with azygos vein continuation.

[Echocardiography in the catheterization unit]. / L'échocardiographie en salle de cathétérisme.

Non-coronary interventional cardiology has for about ten years been undergoing significant development, with the arrival of new percutaneous procedures in various domains. Some of them have already been well validated, notably percutaneous mitral comissurotomy, percutaneous closure of inter-atrial (IA) communications and patent foramen ovale, trans-septal catheterisation, and alcohol septal ablation of hypertrophic obstructive cardiomyopathy. Other interventional techniques are still in the validation phase, such as the techniques for percutaneous occlusion of the left atrium, percutaneous implantation of valvular prostheses, or the new approaches to percutaneous treatment of mitral valvulopathy. The rapid development of these techniques has benefited widely from the use of echocardiography in the catheter suite, providing a very precise clarification of the anatomy and continuous guidance during procedures. This echocardiographic guidance provides optimal results for the interventional procedure and reduces the incidence of complications.

[Feasibility of percutaneous exclusion of the left atrial appendage: results of 11 cases]. / Faisabilité de l'exclusion percutanée de l'auricule gauche. A propos de 11 cas.

Atrial fibrillation is associated with a risk of cerebral embolism, the only proven effective prevention of which is anticoagulant therapy. There is no known alternative in cases with contra-indications to this treatment. Percutaneous exclusion of the left atrial appendage by the implantation of a prosthesis (PLAATO System, ev3 Inc., Plymouth, Minnesota) is a new approach to the prevention of these complications. The authors report the results observed in a series of 11 consecutive patients (7 men, mean age 72 +/- 9 years) in whom this procedure was proposed. All patients had atrial fibrillation for over 3 months, were at high risk and had contra-indications to oral anticoagulants. The implantation of the prosthesis was performed after treatment with aspirin and clopidogrel, under general anaesthesia radioscopy and transoesophageal echocardiographic guidance with success in 9 cases (1 implantation refused in the catheter laboratory and 1 failure). The only complication observed was transient ST elevation treated by emergency angioplasty. The echographic and angiographic criteria of success of left atrial appendage exclusion were fulfilled in all implanted patients. The hospital course was uncomplicated. One recurrence of stroke was observed at the second month: transoesophageal echocardiography confirmed the absence of thrombosis, of migration of the prosthesis and its impermeability in all the patients. After 7 +/- 5 months' follow-up, no other adverse event was observed. This new procedure is technically feasible. Despite encouraging results, its long-term efficacy in the prevention of thromboembolic complications of atrial fibrillation remains to be demonstrated.