Watchful waiting care or early intervention in asymptomatic severe aortic stenosis: Where we are.

Aortic stenosis, the most common valvular heart disease in Western countries, affects predominantly older people. Prompt aortic valve replacement is undoubtedly indicated in symptomatic patients. Management of asymptomatic patients is nowadays shifting from a conservative approach to early aortic valve replacement, as multimodality imaging is increasingly available. However, multimodality imaging has led to multiple prognostic parameters and complex algorithms, as well as a new staging classification that has left patients and physicians somewhat puzzled. We highlight the value of thorough serial clinical examinations, Doppler echocardiography and exercise testing when caring for a growing aortic stenosis population, including that has no or limited access to multimodality imaging. Evidence for early aortic valve replacement versus conservative management in asymptomatic patients with severe aortic stenosis is biased by the lack of serial stress testing evaluation; 30% of so-called asymptomatic patients were in fact symptomatic, and thus were clear candidates for aortic valve replacement in the above-mentioned studies. Randomized trials of aortic valve replacement versus conservative management that include serial stress testing evaluation are needed to ascertain whether early aortic valve replacement actually improves clinical outcome in asymptomatic patients with severe aortic stenosis. Less interventional medicine and healthcare resource utilization can result in better health.

Patients with high left ventricular filling pressure may be missed applying 2016 echo guidelines: a pilot study.

2016 guidelines for the echographic evaluation of left ventricular filling pressure (LVFP) proposed a single algorithm with limited number of criteria (E/A ratio, tricuspid regurgitation velocity, left atrial volume index and average E/e') mainly related to left atrial pressure. Pulmonary venous flow analysis, evaluating more specifically left ventricular end diastolic pressure (LVEDP) has been withdrawn. We aim to evaluate the proportion of patients diagnosed with normal LVFP according to 2016 recommendations, despite an abnormal pulmonary venous flow profile suggesting high LVEDP. We prospectively studied patients with stable ischemic cardiomyopathy and aortic stenosis, before cardiac surgery. Extensive echocardiography was performed including pulmonary and mitral A wave durations. We included 76 patients (mean age 72 ± 10 years, 78% were men), 37 (49%) with aortic stenosis and 22 (29%) with ischemic cardiomyopathy. Mean left ventricular ejection fraction was 67 ± 11%. Applying recommendations, 58 patients had normal LVFP and 15 patients had high LVFP. Among the 58 patients with normal LVFP, 26 patients had Apd-Amd duration > 30 ms highly suggestive of high LVEDP. These patients had higher LV mass (112 ± 30 g/m2 vs. 86 ± 20 g/m2, p = 0.004) and shorter A wave duration (120 ± 13.6 ms vs. 132 ± 16.5 ms, p = 0.006) as compared to the remaining 15 patients with concordant evaluation (normal LVFP and normal Apd-Amd). In the present study, we found that 26/58 patients with low LVFP according to the 2016 recommendations had Apd-Amd suggestive of high LVEDP. Pulmonary venous flow should be added to the algorithm, particularly in patients with unexplained symptom, high LV mass or truncated mitral A wave.

Skeletal myoblast transplantation in ischemic heart failure: long-term follow-up of the first phase I cohort of patients.

BACKGROUND: Skeletal myoblast (SM) transplantation (Tx) in a post-myocardial infarction (MI) scar experimentally improves left ventricular (LV) ejection fraction (EF). Short-term follow-up (FU) studies have suggested that a similar benefit could clinically occur despite an increased risk of LV arrhythmias. METHODS AND RESULTS: We report the long-term FU of the first worldwide cohort of grafted patients (n = 9, 61.8+/-11.6 years, previous MI, EF < or = 35%) operated on (autologous SM Tx and bypass surgery) in 2000 to 2001 and evaluated before Tx, at 1 month (M1) and at a median FU of 52 (18 to 58) months after Tx (37 patient-years). NYHA class improved from 2.5+/-0.5 to 1.8+/-0.4 at M1 (P=0.004 versus baseline) and 1.7+/-0.5 at FU (P=not significant versus M1; P=0.0007 versus baseline). EF increased from 24.3+/-4% to 31+/-4.1% at M1 (+28%, P=0.001 versus baseline) and remained stable thereafter (28.7+/-8.1%, +18% versus baseline). There were 5 hospitalizations for heart failure in 3 patients at 28.6+/-9.9 months, allowing implant in 2 patients with a resynchronization pacemaker. An automatic cardiac defibrillator (ACD) was implanted in 5 patients for nonsustained (n =1) or sustained (n =4) ventricular tachycardia at 12.2+/-18.6 (1 to 45) months. Despite a beta-blocker/amiodarone combination therapy, there were 14 appropriate shocks for 3 arrhythmic storms in 3 patients at 6, 7, and 18 months after ACD implantation. CONCLUSIONS: In this cohort of severe heart failure patients both clinical status and EF stably improve over time with a strikingly low incidence of hospitalizations for heart failure (0.13/patient-years) and the arrhythmic risk can be controlled by medical therapy and/or on-request ACD implantation.

Preoperative right ventricular dysfunction is a strong predictor of 3 years survival after cardiac surgery.

BACKGROUND: Prognostic value of right ventricular (RV) systolic function is well established in valvular disease, heart failure but has not been evaluated in patients undergoing cardiac surgery. OBJECTIVES: The aim of the present study was to evaluate the prognostic value of preoperative RV dysfunction extensively evaluated on the basis of a large set of echocardiographic parameters [S', RV fractional area change (RVFAC), right myocardial performance index (RMPI), isovolumic acceleration (IVA), RV dP/dt and basal longitudinal strain (BLS)] in a large population of unselected patient awaiting cardiac surgery. METHODS: We prospectively studied 400 consecutive patients referred for cardiac surgery, in a single surgical center. Echocardiography was performed 24 h before surgery and phone interview assessed the survival status (overall and cardiovascular death) 3-years after surgery. RESULTS: Among 400 patients, 271 were male, mean age was 70.3 ± 10.2. At 3-years the overall and cardiovascular mortality was, respectively, 10.5 and 6.8%. The univariate Cox analysis identified all RV function parameters excepted BLS as predictive factors of overall mortality, with the strongest value for RVFAC < 35% (HR 4.8), S' < 10 cm/s (HR 3.8) and IVA < 1.8 m/s2 (HR 3.2) (all P < 0.001). All parameters were associated to cardiovascular mortality. In multivariate analysis, RVFAC, S', dP/dt and IVA were significantly associated to 3-years overall mortality whatever the EuroSCORE. Abnormal RVFAC, S', IVA and BLS were associated to cardiovascular mortality. CONCLUSIONS: The presence of RV dysfunction before cardiac surgery assessed by echo significantly predicts postoperative mortality, and this is true whatever the EuroSCORE level. This result demonstrates the need of adding the assessment of echographic RV function before cardiac surgery.

Serial left ventricular adaptations in world-class professional cyclists: implications for disease screening and follow-up.

OBJECTIVES: The purpose of this research was to study long-term left ventricular (LV) adaptations in very-high-level endurance athletes. BACKGROUND: Knowledge of cardiac changes in athletes, who are at particularly high risk of sudden cardiac death, is mandatory to detect hypertrophic cardiomyopathy (HCM) or dilated (DCM) cardiomyopathy. METHODS: We carried out echocardiographic examinations on 286 cyclists (group A) and 52 matched sedentary volunteers (group C); 148 cyclists participated in the 1995 "Tour de France" race (group A1), 138 in the 1998 race (group A2), and 37 in both (group B). RESULTS: In groups A, A1, A2, and C, respectively, diastolic left ventricular diameter (LVID) was 60.1 +/- 3.9 mm, 59.2 +/- 3.8 mm, 61.0 +/- 3.9 mm, and 49.0 +/- 4.3 mm (A vs. C and A1 vs. A2, p < 0.0001), and maximal wall thickness (WT) was 11.1 +/- 1.3 mm, 11.6 +/- 1.3 mm, 10.6 +/- 1.1 mm, and 8.6 +/- 1.0 mm (A vs. C and A1 vs. A2, p < 0.0001). Among group A, 147 (51.4%) had LVID >60 mm; 17 of them had also a below normal (<52%) left ventricular ejection fraction (LVEF). Wall thickness exceeded 13 mm in 25 athletes (8.7%) (always <15 mm), 23 with LVID >55 mm. In group B, LVID increased (58.3 +/- 4.8 mm to 60.3 +/- 4.2 mm, p < 0.001) and WT decreased (11.8 +/- 1.2 mm to 10.8 +/- 1.2 mm, p < 0.001) with time. CONCLUSIONS: Over one-half of these athletes exhibited unusual LV dilation, along with a reduced LVEF in 11.6% (17 of 147), compatible with the diagnosis of DCM. Increased WT was less common (always <15 mm) and scarce without LV dilation (<1%), eliminating the diagnosis of HCM. Serial examinations showed evidence of further LV dilation along with wall thinning. These results might have important implications for screening in athletes.

Autologous skeletal myoblast transplantation for severe postinfarction left ventricular dysfunction.

OBJECTIVES: This phase I trial was designed to assess the feasibility and safety of autologous skeletal myoblast transplantation in patients with severe ischemic cardiomyopathy. BACKGROUND: Experimentally, myoblast grafting into postinfarction myocardial scars improves left ventricular function. METHODS: Ten patients were included on the basis of the following criteria: 1) severe left ventricular dysfunction (ejection fraction < or = 35%); 2) the presence of a postinfarction akinetic and nonviable scar, as assessed by dobutamine echocardiography and 18-fluorodeoxyglucose positron emission tomography; and 3) an indication of coronary bypass in remote areas. Skeletal myoblasts were grown from a biopsy taken at the thigh. RESULTS: An average of 871 x 10(6) cells (86% of myoblasts) were obtained after a mean period of 16 days and implanted uneventfully across the scar at the time of bypass. Except for one patient whose early death was unrelated to the cell transplantation, all patients had an uncomplicated postoperative course. Four patients showed delayed episodes of sustained ventricular tachycardia and were implanted with an internal defibrillator. At an average follow-up of 10.9 months, the mean New York Heart Association functional class improved from 2.7 +/- 0.2 preoperatively to 1.6 +/- 0.1 postoperatively (p < 0.0001), and the ejection fraction increased from 24 +/- 1% to 32 +/- 1% (p < 0.02). A blinded echocardiographic analysis showed that 63% of the cell-implanted scars (14 of 22) demonstrated improved systolic thickening. One noncardiac death occurred 17.5 months after transplantation. CONCLUSIONS: These preliminary data suggest the feasibility and safety of autologous skeletal myoblast transplantation in severe ischemic cardiomyopathy, with the caveat of an arrhythmogenic potential. New-onset contraction of akinetic and nonviable segments suggests a functional efficacy that requires confirmation by randomized studies.

Effects of carvedilol on myocardial sympathetic innervation in patients with chronic heart failure.

UNLABELLED: Carvedilol is a beta-blocking agent with antioxidant properties that has been shown to improve survival in chronic heart failure (CHF). Previous open-label studies have suggested that its use may have positive effects on the abnormalities of cardiac sympathetic innervation integrity and functioning. The present study aimed to test the hypothesis that carvedilol exerts its beneficial effects on hemodynamics in parallel with an action on myocardial sympathetic activity and with its antioxidant property. METHODS: A randomized, multicenter, double-blind, placebo-controlled study of carvedilol was conducted on 64 CHF patients. Patients underwent-before and after 6 mo of therapy with either carvedilol or placebo-measurements of cardiac sympathetic activity, circulating catecholamine level, and hemodynamic indices. Myocardial meta-(123)I-iodobenzylguanidine ((123)I-MIBG) uptake was used to assess the changes in myocardial sympathetic activity. The antioxidant properties of the plasma were assessed by measuring the percentage of nonhemolyzed erythrocytes and the volume of plasma capable of inhibiting 50% of hemolysis after an oxidative stress. Echographic left ventricular (LV) diameters, radionuclide LV ejection fraction (LVEF), and exercise cardiopulmonary capacity were measured to evaluate the hemodynamic response. RESULTS: End-diastolic and end-systolic LV diameters decreased (both P < 0.05) and LVEF increased (P = 0.03) in the carvedilol group, whereas these parameters remained unchanged in the placebo group. Carvedilol did not alter the submaximal exercise cardiopulmonary capacity or the circulating catecholamine level. The beneficial hemodynamic effects in the carvedilol group were associated with an increase in myocardial (123)I-MIBG uptake as assessed by both planar and tomographic imaging (P < 0.01). Carvedilol had no detectable effect on antioxidant properties of the plasma. CONCLUSION: The benefits of carvedilol on resting hemodynamics appear to be associated with a partial recovery of cardiac adrenergic innervation functioning without detectable antioxidant effect in the plasma.

Optimization of factor analysis of the left ventricle in echocardiography for detecting wall motion abnormalities.

This study has tested solutions to optimize the ability of factor analysis of the left ventricle in echocardiography (FALVE) to detect segmental wall motion abnormalities automatically. On four- and two-chamber views of 38 patients, two factors (one flat curve and one curve describing the contraction-relaxation sequence) were extracted and associated factor images were combined to synthesize a parametric image (constant image in green, positive/negative values of the contraction-relaxation image in red/blue). The segments were graded on the visual and the parametric views. The impact of selecting a whole cardiac cycle, masking the left ventricle and realigning the image sequence on the results, was demonstrated. Systematic realignment had a positive impact, especially for patients with left bundle branch block or pacemaker. After alignment, for the entire population, the absolute concordance was 68.6% and the relative concordance (within one grade) was 99%. Thus, FALVE is promising for detecting segmental wall motion abnormalities.

Chronic cor pulmonale: a rare complication of undiagnosed pacemaker lead endocarditis.

Pacemaker lead infection is a rare life-threatening complication of permanent transvenous pacing. We describe the case of a young man who suffered recurrent undiagnosed septic pulmonary embolisms from pacemaker lead vegetations inducing chronic cor pulmonale with major pulmonary arterial hypertension. The potential complications of transvenous pacing and the systematic use of transesophageal echocardiography are emphasized.

Echocardiographic assessment of right ventricular systolic function in a population of unselected patients before cardiac surgery: a multiparametric approach is necessary.

BACKGROUND: According to recent USA guidelines, right ventricular (RV) dysfunction can be diagnosed on the basis of a single parameter, such as tricuspid lateral annular systolic velocity (S')<10 cm/s or RV fractional area change (RVFAC)<35%. AIMS: To assess these recommendations in a large unselected cohort of patients awaiting cardiac surgery and evaluate less validated RV function criteria. METHODS: Among the consecutive patients, 413 were prospectively enrolled and underwent comprehensive echocardiography, including S', RVFAC and other RV parameters (right myocardial performance index; acceleration time, isovolumic velocity and isovolumic acceleration [IVA]; RV dP/dt; isovolumic relaxation time; two-dimensional [2D] strain). We defined subgroups of highly probable RV dysfunction (S'<10 cm/s and RVFAC<35%) and highly probable normal RV function (S'≥10 cm/s and RVFAC≥35%) as reference groups. Indices of preload and afterload were also recorded. RESULTS: Of 413 patients, 320 (77.5%) had normal RV function. In 93 patients, S' and/or RVFAC were abnormal; both were abnormal in 39 (42%) patients. Using our reference groups, IVA≤1.8 m/s2 and basal 2D strain≥-17% were of most value in diagnosing RV dysfunction. IVA was least load dependent while basal 2D strain appeared to be afterload and preload dependent. CONCLUSION: In this large population, S' and RVFAC were sometimes discrepant, supporting the need for a multiparametric approach when evaluating RV function. Among seven less validated criteria, IVA and 2D strain had the best diagnostic value. Unlike 2D strain, IVA was not influenced by loading conditions.

Improving stress echocardiography accuracy for detecting left circumflex artery stenosis: a new echocardiographic sign?

BACKGROUND: The accuracy and reproducibility of stress echocardiography (SE) for the detection of coronary artery lesions requires improvement, particularly in the left circumflex artery (LCx). AIMS: To evaluate the feasibility and diagnostic value of a new sign: Rise of the Apical lateral wall and/or Horizontal displacement of the Apex toward the septum ("RA-HA") in apical echocardiographic views. METHODS: Consecutive patients with normal left ventricular function at rest, positive SE and an indication for coronary angiography were included. SEs were analysed blindly by three independent cardiologists: two seniors (S1 and S2) and one junior (J). RESULTS: Of 81 patients, 58 had an exercise SE and 23 had a dobutamine SE. Significant coronary stenosis was found in 59 of 77 patients who underwent coronary angiography (76.6%). Interobserver reproducibility for the presence of RA-HA was very good between S1 and S2 (κ = 0.86), and good between S1 and J (0.67) and S2 and J (0.70). The sensitivity, specificity and positive and negative predictive values of RA-HA for the detection of significant coronary artery stenosis were, respectively, 39-41%, 83-89%, 88-92% and 29-31% for S1/S2; and 29%, 83%, 85% and 26% for J. To predict LCx stenosis (single or multivessel): 67-70%, 89%, 80-81% and 80-82% for S1/S2, respectively, and 50%, 89%, 75% and 74% for J. CONCLUSION: With a short learning curve, RA-HA is easily diagnosed with a very good interobserver reproducibility. It has high specificity and PPV for the detection of a coronary artery stenosis, particularly in the LCx artery, during exercise or dobutamine SE.

How to calculate left ventricular mass in routine practice? An echocardiographic versus cardiac magnetic resonance study.

BACKGROUND: An accurate assessment of left ventricular (LV) mass is important for the detection of LV hypertrophy. AIMS: To assess the accuracy of four echocardiographic imaging modalities for assessing LV mass compared with cardiac magnetic resonance (CMR). METHODS: We prospectively studied 40 consecutive patients, who underwent an echocardiographic examination using four imaging modalities (M-mode fundamental imaging [FI], M-mode harmonic imaging [HI], two-dimensional [2D] FI and 2D HI) and CMR (our gold standard for LV mass measurement). All echocardiographic measurements were performed by two independent observers. RESULTS: All echocardiographic modes significantly overestimated LV mass compared with CMR (P≤0.04), except 2D FI (P=0.25). This overestimation was significantly higher with HI (up to 15.5%) compared with FI (up to 5.7%; P≤0.04). Significant correlations were observed between the different echocardiographic methods and the two observers. The interobserver agreement over LV mass measurement was lower with FI (intraclass coefficient [ICC] range, 0.66-0.73) than with HI (ICC range, 0.72-0.82), and the best agreement was obtained with 2D HI (ICC, 0.82). Good agreement between CMR and all echocardiographic methods was observed among the smallest LV diameters (ICC range, 0.62-0.85), but not among the largest LV diameters (ICC range, 0-0.22). CONCLUSIONS: HI overestimates LV mass compared with FI and CMR; this leads to overestimation of prevalence of LV hypertrophy in a population of hypertensive patients. HI improves interobserver reproducibility of LV mass measurement compared with FI, leading to a significant decrease in the number of patients required for clinical trials evaluating LV mass regression. Accuracy of LV mass measurement by echocardiography is affected by LV geometry.