Chronic kidney disease is a key risk factor for aortic stenosis progression.

BACKGROUND: Rapid progression of aortic stenosis (AS) has been observed in patients undergoing dialysis, but existing cross-sectional evidence is contradictory in non-dialysis-dependent chronic kidney disease (CKD). The present study sought to evaluate whether CKD is associated with the progression of AS over time in a large cohort of patients with AS. METHODS: We retrospectively studied all consecutive patients diagnosed with AS [peak aortic jet velocity (Vmax) ≥2.5 m/s] and left ventricular ejection fraction ≥50% in the echocardiography laboratories of two tertiary centers between 2000 and 2018. The estimated glomerular filtration rate (eGFR) (mL/min/1.73 m2) was calculated from serum creatinine values. Patients were divided into five CKD stages according to the baseline eGFR. Annual rates of change in the aortic valve area (AVA) were determined by a linear mixed-effects model. RESULTS: Among the 647 patients included, 261 (40%) had CKD. After a median follow-up of 2.9 (interquartile range 1.8-4.8) years, the mean overall rate of change in AVA was -0.077 (95% confidence interval -0.082; -0.073) cm2/year. There was an inverse relationship between the progression rate and kidney function. The more severe the CKD stage, the greater the AVA narrowing (P < .001). By multivariable linear regression analysis, the eGFR was also negatively associated (P < .001) with AS progression. An eGFR strata below 45 mL/min/1.73 m2 was associated with higher odds of rapid progression of AS than normal kidney function. During the clinical follow-up, event-free survival (patients free of aortic valve replacement or death) decreased as CKD progressed. Rapid progression of AS in patients with kidney dysfunction was associated with worse outcomes. CONCLUSIONS: Patients with CKD exhibit more rapid progression of AS over time and require close monitoring. The link between kidney dysfunction and rapid progression of AS is still unknown and requires further research.

Anatomical and biometric study of the radial artery on human cadavers dissected in the anatomy laboratory.

OBJECTIVE: To study the anatomy and biometry of the radial artery and to report the implications of this study for daily practice in Cardiac Surgery. METHOD: Radial arteries from 45 human cadavers (28 males and 17 females, average age 79.2 (92) fixed in 10% formalin were dissected. The proximal and distal internal calibers and lengths of these radial arteries were measured. RESULTS: Our results showed the presence of a single radial artery variation in 2.3% of the entire sample (1.1% of the 90 dissected upper limbs). The distance between the epicondyle and the emergence of the radial artery was 32.4 (6.67) mm in men and 30.7 (9.00) mm in women, with an average of 31.8 (7.58) mm. For the right upper limb, the mean proximal internal caliber of the radial artery was 3.16 (0.56) mm and its mean distal internal caliber was 2.62 (0.66) mm. For the left upper limb, the mean proximal internal caliber of the radial artery was 3.17 (0.59) mm and its mean distal internal caliber was 2.64 (0.68) mm. The mean length of the left radial artery was 197.0 (17) mm. The mean length of the right radial artery was 201.0 (33) mm. CONCLUSION: It is very important to be aware of the possible anatomical variation of the radial artery. Despite its rarity, this knowledge may ensure a better safety and reliability of the harvesting technique for use as a graft.

Anatomical Mitral Valve Repair: Mathematical Prediction of Artificial Chordae Length in Para-Commissural Regions.

To develop a mathematical formula for calculating the length of ruptured mitral valve chordae (with a view to surgically replacing them with artificial chordae) when rupture occurs at scallop A1, A3, P1, or P3. We studied human cadaver hearts collected by the Faculty of Medicine at Amiens Picardy University Hospital. The donors' mean age standard deviation age at death was 79 ± 10. After weighing and dissection, we counted the number of para-commissural chordae per scallop and measured their length with a digital calliper. A total of 31 human cadaver hearts (14 from females and 17 from males) were analyzed. The mean lengths of scallops A1, A2, A3, P1, P2, and P3 were 17.45, 19.42, 17.58, 13.32, 14.52, and 13.26 mm, respectively. A linear regression gave the following mathematical equations: A1 = 0.96 × A2- - 1.3 (R: 0.99; P < 0.001); A3 = 0.9 × A2 + 0.17 (R: 0.95; P < 0.01); P1 = 0.87 × P2 +0.74 (R: 0.89; P < 0.001), and P3 = 0.91 × P2 - 0.01 (R: 0.87; P < 0.0001). When the patient's anatomy prevents manual measurements of the chordae during mitral valve repair surgery, the mathematical formulae derived here can be used to predict the length of the chordae on A1, A3, P1, and P3 from the length of the chordae on A2 and P2. The mitral chordae can therefore be replaced with prostheses with a great degree of precision.

Analysis of cardiovascular risk factors: a retrospective epidemiological study in Guinea in 2022.

OBJECTIVE: This study presents a comprehensive descriptive and comparative analysis of a Guinean cohort, focusing on geographical variables and medical histories in relation to family backgrounds and cardiovascular risk scores. The primary goal is to enhance understanding of cardiovascular risk factor distribution within the Guinean population and identify significant correlations among the investigated variables. PATIENTS & METHODS: In this retrospective study, data from 2435 Guinean patients in 2022 were analyzed based on demographic and medical variables. Cardiovascular risk scores were calculated following Guinea's national program guidelines for non-communicable disease prevention and control. Rigorous data collection, including retrospective analyses and screening campaigns, was conducted in collaboration with the Fondation pour le Diabète et les Maladies Non Transmissibles de Conakry. Statistical tests, including one-way ANOVA, Kruskal-Wallis, Pearson Chi², V Cramer, Fisher exact, and Mann-Whitney U, were applied for a comprehensive comparative analysis. RESULTS: Analysis across five cardiovascular risk score levels revealed significant variations in gender, region, and tuberculosis prevalence. Gender differences were notable, with a female predominance in both groups, slightly higher in the 10 % or more risk group. The higher-risk group exhibited a greater proportion of fasting blood glucose measurements. CONCLUSIONS: Effectively assessing and managing hypertension, diabetes, and other pathologies requires considering factors such as geographic area, family history, cardiovascular risk score, and gender for accurate evaluation. These factors influence pathology prevalence and should be considered in individualized prevention and management strategies. The study underscores the importance of tailored measures to enhance disease management and reduce associated risks.

Optimizing coronary artery opacification and 3D reconstruction from human cadaver hearts in anatomy research.

OBJECTIVE: This study seeks to identify the ideal dilution rate of a radiopaque product to optimize the visualization of coronary arteries and their branches within human cadaver hearts. The process involves obtaining images in the anatomy laboratory and subsequently constructing a three-dimensional model. MATERIALS AND METHODS: We utilized 30 human hearts fixed in 10 % formalin (9 females and 21 males) with a mean age of 79 ± 5 years. The initial experiment, involving the first four hearts (referred to as "group 1"), encountered difficulties in opacifying coronary arteries. In this phase, a probabilistic injection of 20 % Visipaque and 80 % latex, with coronary sinus ostium closure, was performed. The optimal mixture ratio was then determined as 33 % Visipaque and 66 % latex. Recognizing the need for on-site injection at the CT Scan table, this protocol was applied to the subsequent 11 hearts in "group 2." Closure of the coronary sinus was deemed unnecessary. The final 15 hearts, constituting "group 3," revealed that the injection should be gradual, maintaining controlled pressure between 120 and 150 mm Hg. Post-injection, hearts were scanned with the injected coronary arteries using an Optima 660 CT scanner. Two-dimensional images were acquired with parameters set at 64 × 0.625 mm, 100 kV, 300-400 mA, and a rotation of 0.5 s. Subsequently, 3D reconstruction was conducted using Advantage Workstation 4.7 (GE Healthcare) and volume rendering with Volume Viewer software, version 15. RESULTS: Significant differences in the percentage of opacified coronaries were observed among the three groups (p < 0.005). This variation underscores the learning curve and comprehension required before establishing a reliable method. Group 1 (N = 4) demonstrated minimal opacification, group 2 (N = 11) displayed partial opacification, while group 3 (N = 15) achieved 100 % opacification of coronary arteries. CONCLUSION: The successive experiments culminated in the development of a protocol for CT imaging, enabling accurate three-dimensional reconstruction of the normal anatomy of the main and secondary coronary arteries. Our work is grounded in a series of progressively refined and successful experiments.

Influence of age and sex on the thickness of the radial artery wall.

OBJECTIVE: The aim of this study is to investigate whether there is a relationship between age or sex and the thickness of the radial artery wall. MATERIALS AND METHODS: We harvested human radial arteries from 48 cadavers (30 men and 18 women) in the anatomy laboratory. Histological sections of 3 µm thickness were prepared at the Laboratory of Anatomy and Pathological Cytology, mounted on slides, and stained with hematoxylin-phloxine-safran, Masson's trichrome, and orcein. The thickness of each radial artery wall (intima-media thickness) was measured using optical microscopy, and an average measurement was established among the three thicknesses (upper third, middle third, and lower third). STATISTICAL METHODS: Statistical analyses were performed using the R software. Means and standard deviations were utilized. A correlation analysis was also conducted to assess the relationship between radial artery wall thickness and subjects' age. RESULTS: On average, the thickness of the left radial artery wall and that of the right radial artery measured 282 (34) micrometers (µm). We found a correlation between radial artery wall thickness and age in both men (p < 0.001) and women (p < 0.001). CONCLUSIONS: In conclusion, this study elucidates that radial artery wall thickness is related to age and sex in its assessment.

Anatomical and biometric study of the mitral valve apparatus: application in valve repair surgery.

OBJECTIVE: Most mitral valve repair techniques provide excellent surgical results by removing regurgitation, but all of these techniques simultaneously reduce posterior valve mobility. A comprehensive biometric study of the mitral valve apparatus will provide landmarks that would help improve this posterior valve mobility. MATERIALS AND METHODS: Thirty one (31) human hearts have been studied, from 14 women and 17 men. The characteristics of the studied sample were analyzed descriptively. The difference in means of the variables between women and men were tested using a Student t test. Correlations between the different measures were determined by simple regression analysis. Mean values are shown with ± 1 standard deviation and the limit of significance was set at 0.05. RESULTS: The mean weight of the hearts was 275.3 ± 2.4 g. The anteroposterior diameter of the mitral annulus was 29.3 ± 1.22 mm, the intertrigonal distance was 25.2 ± 3.50 mm and the anterior leaflet to posterior leaflet ratio was 1.9 ± 0.10, the length of the chordae A2 = 19.4 ± 1.15 mm and P2 = 14.5 ± 0.85 mm. The length of the anterior papillary muscle averaged 30.9 ± 7.20 mm and that of the posterior one 30.0 ± 8.75 mm. The comparison of the different values measured between women and men showed no statistically significant difference (p > 0.05). There was no correlation between these different measured values (p > 0.05). CONCLUSION: A perfect knowledge of anatomy and biometry is therefore essential to offer alternative techniques that reproduce the real anatomy and physiology with a complete reconstruction of the mitral valve.

Modeling of mitral chordae's length in echocardiography as a function of their manual measurement in the operating room.

OBJECTIVE: In mitral insufficiency, trans-esophageal echocardiography (TEE) analysis of the mitral valve is an indispensable and irreplaceable examination to establish precisely the type of surgical repair to be performed and the exact length of neo-chordae to be used for an anatomical repair. The aim of our study is to find a predictive model of the Echographic Measurement (EM) variable according to the Manual Measurement (MM) variable of the mitral valve chordae, when the echocardiography measurement is not feasible. PATIENTS AND METHODS: This is a retrospective study on 191 patients undergoing mitral valve repair. The sex ratio (M/F) is 2.13 (130 men and 61 women). The collection of data of mitral chordae measurements performed echographically in preoperatively conditions, and then manually in intraoperatively conditions from January 2008 to December 2016 was made from the medical records of patients at the cardiology and cardiac surgery department of the University Hospital Center of Amiens in Picardy. RESULTS: For this study 191 patients of mean age of 68 ± 13 years were included. The averages of the MM and EM of the mitral chordae were respectively 23 ± 2.5 mm and 24 ± 2.4 mm. The Pearson correlation coefficient was 0.897 (p-value < 10-4) showing a strong positive correlation between MM and EM. The results of the linear regression allow us to found the following mathematical model: EM = 0.87 × MM + 4. CONCLUSIONS: When patients have a contraindication to transesophageal echocardiography or when TEE is not feasible, manual measurement is performed during the surgery. By using the values obtained (MM) in the model, it is possible to predict the corresponding echographic measurements. This allows us to achieve the mitral tendinous chordae substitution with a very high precision. TRIAL REGISTRATION: Retrospectively registered.

Unsupervised clustering of patients with severe aortic stenosis: A myocardial continuum.

BACKGROUND: Traditional statistics, based on prediction models with a limited number of prespecified variables, are probably not adequate to provide an appropriate classification of a condition that is as heterogeneous as aortic stenosis (AS). AIMS: To investigate a new classification system for severe AS using phenomapping. METHODS: Consecutive patients from a referral centre (training cohort) who met the echocardiographic definition of an aortic valve area (AVA) ≤ 1 cm2 were included. Clinical, laboratory and imaging continuous variables were entered into an agglomerative hierarchical clustering model to separate patients into phenogroups. Individuals from an external validation cohort were then assigned to these original clusters using the K nearest neighbour (KNN) function and their 5-year survival was compared after adjustment for aortic valve replacement (AVR) as a time-dependent covariable. RESULTS: In total, 613 patients were initially recruited, with a mean±standard deviation AVA of 0.72±0.17 cm2. Twenty-six variables were entered into the model to generate a specific heatmap. Penalized model-based clustering identified four phenogroups (A, B, C and D), of which phenogroups B and D tended to include smaller, older women and larger, older men, respectively. The application of supervised algorithms to the validation cohort (n=1303) yielded the same clusters, showing incremental cardiac remodelling from phenogroup A to phenogroup D. According to this myocardial continuum, there was a stepwise increase in overall mortality (adjusted hazard ratio for phenogroup D vs A 2.18, 95% confidence interval 1.46-3.26; P<0.001). CONCLUSIONS: Artificial intelligence re-emphasizes the significance of cardiac remodelling in the prognosis of patients with severe AS and highlights AS not only as an isolated valvular condition, but also a global disease.

Clinical significance of energy loss index in patients with low-gradient severe aortic stenosis and preserved ejection fraction.

AIMS: We hypothesized that among patients with low-gradient severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF), reclassification of AS severity as moderate by pressure recovery adjusted indexed aortic valve area (AVAi) = energy loss index (ELI), may identify a subgroup of patients with a better outcome. METHODS AND RESULTS: Three hundred and seventy-nine patients with low-gradient AS (defined by AVAi ≤ 0.6 cm2/m2 and mean aortic pressure gradient < 40 mmHg) and preserved LVEF ≥50% were studied. Reclassification as moderate AS by ELI was defined as AVAi ≤0.6 cm2/m2 but with an ELI >0.6 cm2/m2. Cardiac events [cardiac mortality and/or need for aortic valve replacement (AVR)] during follow-up were studied. One hundred and forty-eight patients (39%) were reclassified as moderate AS by ELI. Reclassification as moderate AS was independently associated with decreased body surface area, normal flow status, decreased left ventricular mass index, and left atrial volume index (all P < 0.05). After adjustment for variables of prognostic interest, reclassification as moderate AS by ELI was associated with a considerable reduction of risk of cardiac events {adjusted hazard ratio (HR) 0.49 [95% confidence interval (CI) 0.33-0.72]; P < 0.001}, need for AVR [adjusted HR 0.52 (95% CI 0.34-0.81); P = 0.004], and cardiac mortality [adjusted HR 0.46 (95% CI 0.22-0.98); P = 0.044]. CONCLUSION: In patients with low-gradient severe AS and preserved LVEF, calculation of ELI permits to reclassify almost 40% of patients as having moderate AS. These reclassified patients have a considerable reduction of the risk of cardiac events during follow-up. Calculation of ELI is useful for decision-making in patients with low-gradient severe AS and preserved ejection fraction.

Spondylodiscitis complicating infective endocarditis.

OBJECTIVE: The primary objective was to assess the characteristics and prognosis of pyogenic spondylodiscitis (PS) in patients with infective endocarditis (IE). The secondary objectives were to assess the factors associated with occurrence of PS. METHODS: Prospective case-control bi-centre study of 1755 patients with definite IE with (n=150) or without (n=1605) PS. Clinical, microbiological and prognostic variables were recorded. RESULTS: Patients with PS were older (mean age 69.7±18 vs 66.2±14; p=0.004) and had more arterial hypertension (48% vs 34.5%; p<0.001) and autoimmune disease (5% vs 2%; p=0.03) than patients without PS. The lumbar vertebrae were the most frequently involved (84 patients, 66%), especially L4-L5. Neurological symptoms were observed in 59% of patients. Enterococci and Streptococcus gallolyticus were more frequent (24% vs 12% and 24% vs 11%; p<0001, respectively) in the PS group. The diagnosis of PS was based on contrast-enhanced MRI in 92 patients, bone CT in 88 patients and 18F-FDG PET/CT in 56 patients. In-hospital (16% vs 13.5%, p=0.38) and 1-year (21% vs 22%, p=0.82) mortalities did not differ between patients with or without PS. CONCLUSIONS: PS is a frequent complication of IE (8.5% of IE), is observed in older hypertensive patients with enterococcal or S. gallolyticus IE, and has a similar prognosis than other forms of IE. Since PS is associated with specific management, multimodality imaging including MRI, CT and PET/CT should be used for early diagnosis of this complication of endocarditis.

Impact of pulmonary hypertension on long-term outcome in patients with severe aortic stenosis.

Aims: Pulmonary hypertension (PH) is common in severe symptomatic left-sided valvular disease, particularly in aging populations. Inconsistent results have been reported concerning the association between PH and adverse outcomes after aortic valve replacement for aortic stenosis (AS). We therefore retrospectively investigated the prognostic significance of PH using peak tricuspid regurgitation velocity (TRV), as defined by the current European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines, in a large cohort of patients with severe AS. Methods and results: One thousand and nineteen patients (541 men; mean age 74 ± 11 years) with severe AS (aortic valve area (AVA) <1 cm2 and/or indexed AVA <0.6 cm2/m2 of body surface area) and LV ejection fraction ≥50% were included. Patients were divided into three groups according to the level of their peak TRV at the time of enrolment: Group 1 (n = 695, 68%) when TRV was ≤2.8 m/s; Group 2 (n = 212, 21%) when TRV was between 2.9 m/s and 3.4 m/s and Group 3 (n = 112, 11%) when TRV was > 3.4 m/s. Median overall follow-up was 31 [6-182] months. On univariate analysis, overall mortality during follow-up was globally different between groups (P < 0.001). On multivariate analysis, Group 3 (TRV >3.4 m/s) exhibited significant excess mortality after adjustment for covariates of prognostic importance (P = 0.032) and after further adjustment for surgery (P = 0.012), using Group 1 as the reference group. Dividing the whole population into two groups with a 3.4 m/s TRV threshold, overall mortality during follow-up was higher in the PH group [hazard ratio (HR) 1.87; 95% confidence interval [1.37-2.56]; P < 0.001)]. On multivariate analysis, after covariate adjustment, including surgery, Group 3 exhibited major excess mortality (adjusted HR 1.46 [1.10-1.95], P = 0.009). Conclusion: This study demonstrates the negative impact of pulmonary pressure, as assessed by current ESC/ERS guidelines, on long-term outcome of patients with severe AS, irrespective of functional status, chronic obstructive pulmonary disease, AS severity and surgery. Baseline TRV should therefore be taken into account in the management of severe AS.

Computed Tomography Aortic Valve Calcium Scoring in Patients With Aortic Stenosis.

BACKGROUND: Computed tomography aortic valve calcium scoring (CT-AVC) holds promise for the assessment of patients with aortic stenosis (AS). We sought to establish the clinical utility of CT-AVC in an international multicenter cohort of patients. METHODS AND RESULTS: Patients with AS who underwent ECG-gated CT-AVC within 3 months of echocardiography were entered into an international, multicenter, observational registry. Optimal CT-AVC thresholds for diagnosing severe AS were determined in patients with concordant echocardiographic assessments, before being used to arbitrate disease severity in those with discordant measurements. In patients with long-term follow-up, we assessed whether CT-AVC thresholds predicted aortic valve replacement and death. In 918 patients from 8 centers (age, 77±10 years; 60% men; peak velocity, 3.88±0.90 m/s), 708 (77%) patients had concordant echocardiographic assessments, in whom CT-AVC provided excellent discrimination for severe AS (C statistic: women 0.92, men 0.89). Our optimal sex-specific CT-AVC thresholds (women 1377 Agatston unit and men 2062 Agatston unit) were nearly identical to those previously reported (women 1274 Agatston unit and men 2065 Agatston unit). Clinical outcomes were available in 215 patients (follow-up 1029 [126-2251] days). Sex-specific CT-AVC thresholds independently predicted aortic valve replacement and death (hazard ratio, 3.90 [95% confidence interval, 2.19-6.78]; P<0.001) after adjustment for age, sex, peak velocity, and aortic valve area. Among 210 (23%) patients with discordant echocardiographic assessments, there was considerable heterogeneity in CT-AVC scores, which again were an independent predictor of clinical outcomes (hazard ratio, 3.67 [95% confidence interval, 1.39-9.73]; P=0.010). CONCLUSIONS: Sex-specific CT-AVC thresholds accurately identify severe AS and provide powerful prognostic information. These findings support their integration into routine clinical practice. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01358513, NCT02132026, NCT00338676, NCT00647088, NCT01679431.