Automated and semi-automated 3D echocardiographic software for aortic annulus sizing in transcatheter aortic valve implantation helps bridge the gap between expert and novice operators.

3D-transesophageal echocardiography (3D-TEE) is an alternative to multidetector row computed tomography (MDCT) for aortic annulus (AoA) sizing in preparation for Transcatheter aortic valve implantation (TAVI). We aim to evaluate how the fully automated (auto) and semi-automated (SA) TEE methods perform compared to conventional manual TEE method and the gold standard MDCT for annulus sizing both in expert and novice operators. In this prospective cohort study, eighty-nine patients with severe aortic stenosis underwent multimodality imaging with 3D-TEE and MDCT. Annular measurements were collected by expert echocardiographers using 3D auto, SA and manual methods and compared to MDCT. A novice in the field of echocardiography retrospectively measured the AoA for all patients using the same methods. TEE measurements, independently of the method used, had good to very good agreement to MDCT. They significantly underestimated aortic annular area and circumference vs. MDCT with the auto method underestimating it the most and the manual method the least (6.5% and 1.3% respectively for area and circumference). For experts, the manual TEE method offered the least systematic bias while the SA method had narrower limits of agreement (LOA). For the novice operator, SA method provided the least bias and narrower LOA vs. MDCT. There is good agreement between novice and experts for all 3 TEE methods but better agreement with auto and SA methods as opposed to manual one. Our study supports the use of 3D-TEE as a complementary method to MDCT for aortic annular sizing. The newer auto and SA software, that requires minimal operator intervention, is an easy to use, reliable and reproducible tool for aortic annulus sizing for experienced operators, and especially less experienced ones.

Discordant Grading of Aortic Stenosis Severity: Echocardiographic Predictors of Survival Benefit Associated With Aortic Valve Replacement.

OBJECTIVES: This study sought to assess the survival benefit associated with aortic valve replacement (AVR) according to different strata of echocardiographic parameters of aortic stenosis (AS) severity, and especially in patients with an aortic valve area (AVA) comprised between 0.8 cm(2) and 1 cm(2). BACKGROUND: Discordant findings between AVA (≤1.0 cm(2)) and mean gradient (MG) (<40 mm Hg) raise uncertainty regarding the actual severity of AS. Some studies suggested that the AVA threshold value to define severe AS should be decreased to 0.8 cm(2) to reconcile these discordances. METHODS: A total of 1,710 patients with documented moderate to severe AS by Doppler echocardiography were separated into 4 strata of AS severity based alternatively on AVA, indexed AVA, MG, or peak aortic jet velocity (Vpeak). We compared the survival rates of medically versus surgically treated patients. To eliminate covariate differences that may lead to biased estimates of treatment effect, a propensity matching with a greedy 5-to-1 digit-matching algorithm was used. RESULTS: Mean AVA was 0.9 ± 0.3 cm(2), mean MG 33 ± 18 mm Hg, and mean Vpeak 3.6 ± 0.9 m/s. A total of 1,030 (60%) patients underwent AVR within 3 months following echocardiographic evaluation. During a mean follow-up of 4.4 ± 3.0 years there were 469 deaths. Patients with an AVA between 0.8 cm(2) and 1.0 cm(2) had a significant observed survival benefit with AVR (hazard ratio: 0.37 [95% confidence interval: 0.21 to 0.63]; p = 0.0002). AVR was also associated with improved survival in patients with MG between 25 mm Hg and 40 mm Hg or Vpeak between 3 m/s and 4 m/s, but only in patients with concomitant AVA ≤1 cm(2) (p = 0.001 vs. p = 0.46 in patients with AVA >1 cm(2)). CONCLUSIONS: These results do not support decreasing the AVA threshold value for severity to 0.8 cm(2) and they confirm that AVR is associated with improved survival in a substantial number of patients with discordant aortic grading.

Arrhythmic Risk Following Recovery of Left Ventricular Ejection Fraction in Patients with Primary Prevention ICD.

BACKGROUND: Left ventricular ejection fraction (LVEF) recovers during follow-up in a significant proportion of patients implanted with a cardioverter defibrillator (ICD) for primary prevention. Little is known about the midterm arrhythmic risk in this population, particularly in relation to the presence or absence of ischemic cardiomyopathy. METHODS AND RESULTS: We retrospectively analyzed 286 patients with an ICD implanted for primary prevention between 2002 and 2010. Patients were divided into two groups based on their last LVEF assessment: (1) Recovery, defined as an LVEF > 35%; and (2) No-Recovery, defined as an LVEF ≤ 35%. Kaplan-Meir curves and multivariate Cox regression analysis were performed separately for patients with ischemic (211 patients) and nonischemic (75 patients) cardiomyopathy. Forty-nine patients (17.1%) had LVEF recovery to >35% at last follow-up. Overall, 72 patients (25.2%) experienced ventricular arrhythmias requiring ICD therapy during a median follow-up of 4.4 years. With multivariate Cox regression, LVEF recovery was associated with a lower arrhythmic risk in the whole cohort (hazard ratio [HR]: 0.38 [0.13-0.85]; P = 0.02) and in the nonischemic cardiomyopathy cohort (HR: 0.10 [0.005-0.55]; P = 0.005), but not in the ischemic cardiomyopathy cohort (HR: 0.84 [0.25-2.10]; P = 0.74). CONCLUSION: In conclusion, patients with nonischemic cardiomyopathy who improved their LVEF to >35% after primary prevention ICD implantation were at very low absolute arrhythmic risk. Our study raises the possibility that the LVEF cutoff to safely withhold ICD replacement might be higher in patients with ischemic compared to nonischemic cardiomyopathy. This will need to be confirmed in prospective studies.

Impact of classic and paradoxical low flow on survival after aortic valve replacement for severe aortic stenosis.

BACKGROUND: Low flow (LF) can occur with reduced (classic) or preserved (paradoxical) left ventricular ejection fraction (LVEF). OBJECTIVES: The objective of this study was to compare outcomes of patients with low ejection fraction (LEF), paradoxical low flow (PLF), and normal flow (NF) after aortic valve replacement (AVR). METHODS: We examined 1,154 patients with severe aortic stenosis (AS) who underwent AVR with or without coronary artery bypass grafting. RESULTS: Among these patients, 206 (18%) had LEF as defined by LVEF of <50%; 319 (28%) had PLF as defined by LVEF of ≥50% but stroke volume indexed to body surface area (SVi) of ≤35 ml ∙ m(-2); and 629 (54%) had NF, as defined by LVEF of ≥50% and SVi of >35 ml ∙ m(2). Aortic valve area was lower in low flow/LVEF groups (LEF: 0.71 ± 0.20 cm(2) and PLF: 0.65 ± 0.23 cm(2) vs. NF: 0.77 ± 0.18 cm(2); p < 0.001). The 30-day mortality was higher (p < 0.001) in LEF and PLF groups than in the NF group (6.3% and 6.3% vs. 1.8%, respectively). SVi and PLF group were independent predictors of operative mortality (odds ratio [OR]: 1.18, p < 0.05; and OR: 2.97, p = 0.004; respectively). At 5 years after AVR, overall survival was 72 ± 4% in LEF group, 81 ± 2% in PLF group, and 85 ± 2% in NF group (p < 0.0001). CONCLUSIONS: Patients with LEF or PLF AS have a higher operative risk, but pre-operative risk score accounted only for LEF and lower LVEF. Patients with LEF had the worst survival outcome, whereas patients with PLF and normal flow had similar survival rates after AVR. As a major predictor of perioperative mortality, SVi should be integrated in AS patients' pre-operative evaluation.

When should we consider the diagnosis of giant cell myocarditis? Revisiting "classic" echocardiographic and clinical features of this rare pathology.

OBJECTIVES: Giant cell myocarditis is a rare and often fatal disorder. According to the American Heart Association, the American College of Cardiology Foundation, and the European Society of Cardiology scientific statements, an endomyocardial biopsy should be done to exclude giant cell myocarditis in unexplained new-onset heart failure of 2 weeks to 3 months duration associated with dilated left ventricle and new ventricular arrhythmias, or Mobitz type II second-degree, or third-degree atrioventricular heart block. CASE PRESENTATIONS: Two hundred thirty-five heart transplants were performed since May 1993 at the Institut universitaire de cardiologie et de pneumologie de Quebec, Canada. Giant cell myocarditis was found in the explanted hearts of 5 patients. The preoperative diagnosis of giant cell myocarditis was done by endomyocardial biopsy or at the installation of a left ventricular-assisted device. Patients had symptoms of progressive heart failure of subacute onset. Patients consulted at a mean 32 days after the onset of symptoms. Two patients neither had ventricular arrhythmia nor heart block. Two patients had ventricular arrhythmias and heart block; the other patient had symptomatic heart block. All patients had at least 2 echocardiographies. Two patients had an increase in left ventricular size, enough to reach the criteria of left ventricular dilatation according to the American Society of Echocardiography. During this time, left ventricular ejection fraction showed a rapid decline (mean 37% to 16%). CONCLUSIONS: Ventricular arrhythmia, heart block, and left ventricular dilatation initially can be absent in many patients having giant cell myocarditis with symptoms of progressive heart failure. Endo-myocardial biopsy should be quickly considered in patients with a rapid and dramatic decline of left ventricular ejection fraction, even in the absence of classic clinical and echocardiographic features of giant cell myocarditis to rapidly obtain the diagnosis of this rare but lethal disease.

Romiplostim efficacy in an acute myeloid leukemia patient with transfusion refractory thrombocytopenia.

BACKGROUND: Refractoriness to platelet (PLT) transfusion is a feared, life-threatening complication in hematology-oncology patients. Despite increased PLT requirement and treatment costs, the clinical management is difficult and these patients had less favorable outcomes. CASE REPORT: We report on the efficacy of the thrombopoietic agent romiplostim in a patient with acute myeloid leukemia with chemotherapy-induced transfusion-refractory thrombocytopenia. CONCLUSION: Romiplostim could be very helpfull in the management of AML patients with transfusion refractory thrombocytopenia.