Transfemoral tricuspid valve replacement and one-year outcomes: the TRISCEND study.

BACKGROUND AND AIMS: For patients with symptomatic, severe tricuspid regurgitation (TR), early results of transcatheter tricuspid valve (TV) intervention studies have shown significant improvements in functional status and quality of life associated with right-heart reverse remodelling. Longer-term follow-up is needed to confirm sustained improvements in these outcomes. METHODS: The prospective, single-arm, multicentre TRISCEND study enrolled 176 patients to evaluate the safety and performance of transcatheter TV replacement in patients with ≥moderate, symptomatic TR despite medical therapy. Major adverse events, reduction in TR grade and haemodynamic outcomes by echocardiography, and clinical, functional, and quality-of-life parameters are reported to one year. RESULTS: Enrolled patients were 71.0% female, mean age 78.7 years, 88.0% ≥ severe TR, and 75.4% New York Heart Association classes III-IV. Tricuspid regurgitation was reduced to ≤mild in 97.6% (P < .001), with increases in stroke volume (10.5 ± 16.8 mL, P < .001) and cardiac output (0.6 ± 1.2 L/min, P < .001). New York Heart Association class I or II was achieved in 93.3% (P < .001), Kansas City Cardiomyopathy Questionnaire score increased by 25.7 points (P < .001), and six-minute walk distance increased by 56.2 m (P < .001). All-cause mortality was 9.1%, and 10.2% of patients were hospitalized for heart failure. CONCLUSIONS: In an elderly, highly comorbid population with ≥moderate TR, patients receiving transfemoral EVOQUE transcatheter TV replacement had sustained TR reduction, significant increases in stroke volume and cardiac output, and high survival and low hospitalization rates with improved clinical, functional, and quality-of-life outcomes to one year. Funded by Edwards Lifesciences, TRISCEND ClinicalTrials.gov number, NCT04221490.

Diagnostic Impact of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography and White Blood Cell SPECT/Computed Tomography in Patients With Suspected Cardiac Implantable Electronic Device Chronic Infection.

BACKGROUND: Cardiac implantable electronic devices (CIEDs) chronic infection diagnosis is challenging because the clinical presentation is frequently misleading and echocardiography may be inconclusive. The aim of this study was to evaluate the diagnostic value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (CT) and radiolabeled white blood cells single photon emission CT/CT in a cohort of patients who underwent both scans for suspicion of CIED infection and inconclusive routine investigations. METHODS: Forty-eight consecutive patients with suspicion of CIED infection who underwent both 18F-fluorodeoxyglucose positron emission tomography/CT and white blood cell single photon emission CT/CT in a time span ≤30 days were retrospectively included. The final diagnosis of CIED infection by the endocarditis expert team was based on the modified Duke-Li classification at the end of follow-up. 18F-Fluorodeoxyglucose positron emission tomography/CT and white blood cell single photon emission CT/CT scans were independently analyzed blinded to the patients' medical record. RESULTS: In the overall study population, the diagnostic sensitivity, specificity, positive predictive value, and negative predictive value were respectively 80%, 91%, 80%, and 91% for 18F-fluorodeoxyglucose positron emission tomography/CT and 60%, 100%, 100%, and 85% for white blood cell single photon emission CT/CT. Addition of a positive nuclear imaging scan as a major criterion markedly improved the Duke-Li classification at admission. Semiquantitative parameters did not allow to discriminate between definite and rejected CIED infection. Prolonged antibiotic therapy before imaging tended to decrease the sensitivity for both techniques. CONCLUSIONS: Nuclear imaging can improve the diagnostic performances of the Duke-Li score at admission in a selected population of patients with suspected CIED infection, particularly when the infection was initially graded as possible. Whenever possible, imaging should be performed before or early after antibiotic initiation.

Potential Efficiency of Grassy or Shrub Willow Buffer Strips against Nutrient Runoff from Soybean and Corn Fields in Southern Quebec, Canada.

Riparian buffer strips (RBS) are encouraged to control agricultural diffuse pollution. In Quebec Province, Canada, a policy promotes 3-m-wide RBS. Abiding farmers minimally maintain herbaceous vegetation, but nutrient retention efficiency could be improved with woody biomass. This work aimed to assess if fast-growing willows ( Seemen 'SX64') could reduce nutrient loads to a stream, in addition to yielding biomass. Triplicate treatments of two stem densities and a herbaceous control plot were monitored from 2011 to 2013 in a randomized block design on agricultural fields of the St. Lawrence Lowlands with sandy loam (Saint-Roch-de-l'Achigan [SR]) and organic-rich (Boisbriand [BB]) soils. Runoff, interstitial water, and water from the saturated zone were sampled 16 (SR) and 14 (BB) times to quantify nutrient buffering (NO, NH, P, and K). Sampling campaigns followed (i) snowmelt or ≥15-mm natural precipitation events after (ii) fertilization and (iii) glyphosate-based herbicide applications. Concentration reduction before and after the RBS was highest for nitrates (77-81% in runoff at BB, 92-98% at 35- to 70-cm depth at SR) just after fertilization, when edge-of-field concentrations peaked. Total P removal was observed in runoff after fertilization at SR, and K removal was punctually witnessed at BB. Riparian buffer strips were inefficient for NH and dissolved P removal, and RBS effluents exceeded aquatic life protection standards. plantations, irrespective of stem density, were not more efficient than herbaceous RBS. This shows that without fertilizer input reductions, narrow RBS are insufficient to protect streams from excess nutrients in corn ( L.) and soybean [ (L.) Merr.] crops.

Systematic transoesophageal echocardiography after mitral valve replacement: Rates and determinants of paravalvular regurgitation.

BACKGROUND: With the emergence of transcatheter mitral valve replacement, it appears crucial to provide contemporary references with which this new technology can be compared. At our institution, transoesophageal echocardiography is systematically performed before discharge after surgical mitral valve replacement. AIM: To evaluate the rate and determinants of paravalvular regurgitation after surgical mitral valve replacement. METHODS: We collected medical history, indication, type of surgery and in-hospital outcome in all consecutive patients who underwent a mitral valve replacement in the past 2 years at our institution. Paravalvular regurgitation was assessed semiquantitatively using transoesophageal echocardiography before discharge. RESULTS: We enrolled 399 patients (mean age 61±16 years; 58% women; 27% with a history of cardiac surgery). Mitral valve replacement was performed mainly for rheumatic disease (44%). Most patients were severely symptomatic (70% in New York Heart Association class III/IV). A mechanical prosthesis was implanted in 60% and a bioprosthesis in 40%. In-hospital mortality was 10%. Transoesophageal echocardiography was performed in 310 patients (77%); the main reasons for not performing transoesophageal echocardiography were frailty (n=40, 10%), early death (n=19, 5%) and contraindication for transoesophageal echocardiography (n=10, 3%). The overall rate of paravalvular regurgitation was 8% (n=25); a grade ≥2 was observed in five patients (2%), and two patients had to be reoperated on. Mitral annular calcification was the main factor associated with paravalvular regurgitation (P=0.01). CONCLUSIONS: Surgical mitral valve replacement was associated with significant in-hospital mortality and morbidity. Using systematic transoesophageal echocardiography assessment, paravalvular regurgitation was not uncommon (8%), and was significantly linked to mitral annulus calcification. However, clinically significant leakage (≥grade 2) was rare (2%).

Is tricuspid annuloplasty increasing surgical mortality and morbidity during mitral valve replacement? A single-centre experience.

BACKGROUND: Performance of tricuspid annuloplasty (TA) in patients undergoing mitral valve surgery is recommended based on the degree of tricuspid regurgitation and tricuspid annulus size, but is often underused. AIM: To evaluate the impact of combined TA on in-hospital outcome in patients undergoing mitral valve replacement (MVR). METHODS: We selected all consecutive patients who underwent MVR for native valve disease. Clinical, echocardiographic and in-hospital complications were obtained from chart review. RESULTS: We identified 287 patients (mean age 62±17 years; 44% men). Combined TA was performed in 165 patients (57%), who had more rheumatic disease (71% vs. 24%; P<0.0001) and mitral stenosis (55% vs. 22%; P<0.0001), but less endocarditis (4% vs. 31%; P<0.0001), were more often in atrial fibrillation (54% vs. 22%; P<0.0001), were more severely symptomatic (80% vs. 57%; P<0.0001), presented with a higher systolic pulmonary artery pressure (SPAP) (53±16 vs. 45±15mmHg; P=0.0002) and were less likely to have required emergency surgery (17% vs. 38%; P<0.0001). Despite this higher risk profile, in-hospital mortality was slightly lower (5% vs. 13%; P=0.02) and complication rates were similar (redo surgery 22% vs. 16% [P=0.18] and tamponade 20% vs. 15% [P=0.15]). After adjustment for age, sex, functional class, SPAP, emergency surgery and concomitant coronary artery bypass graft or aortic valve replacement surgery, combined TA was not associated with an increased rate of in-hospital death (P=0.08) or major complications (P=0.89). CONCLUSIONS: In a consecutive series of patients who underwent MVR, TA did not seem to have a negative impact on immediate outcome. Hence, additional performance of TA at the time of MVR should not be declined on the basis of an increased surgical risk.

Effects of low concentrations of glyphosate-based herbicide factor 540® on an agricultural stream freshwater phytoplankton community.

Residual glyphosate from glyphosate based herbicides (GBH) are ubiquitously detected in streams draining agricultural fields, and may affect phytoplankton communities present in these ecosystems. Here, the effects of the exposure (96 h) of a phytoplankton community collected in an agricultural stream to various glyphosate concentrations (1, 5, 10, 50, 100, 500 and 1000 µg l-1) of Factor 540® GBH were investigated. The lowest GBH concentration of 1 µg l-1 reduced chlorophyll a and carotenoid contents. Low glyphosate concentrations, such as 5 and 10 µg l-1, promoted changes in the community's structure and reduced the diversity of the main algal species. At glyphosate concentrations ranging from 50 to 1000 µg l-1, the phytoplankton community's composition was modified and new main species appeared. The highest glyphosate concentrations (500 and 1000 µg l-1) affected the shikimate content, the lipid peroxidation and the activity of antioxidant enzymes (superoxide dismutase, catalase and ascorbate peroxidase). These results indicate that GBH can modify structural and functional properties of freshwater phytoplankton communities living in streams located in agricultural areas at glyphosate concentrations much inferior to the 800 µg l-1 threshold set by the Canadian guidelines for the protection of aquatic life.

Phytoplankton growth and PSII efficiency sensitivity to a glyphosate-based herbicide (Factor 540®).

The use of glyphosate-based herbicides in agriculture has increased steadily since the mid 90's and there is now evidence of glyphosate leaching and contamination of aquatic ecosystems. The aim of this study was to evaluate the effects of a glyphosate-based herbicide (Factor 540®) on growth and photosynthetic capacity of algae and cyanobacteria. Six algal and three cyanobacterial species/strains, of three different taxonomic groups, were exposed to five glyphosate concentrations (10, 50, 100, 500 and 1000µgl-1) during 48h. All species have significant growth inhibition at concentrations varying between 50 and 500µgl-1. The photosynthetic response, after glyphosate exposure, varied among species, but a general pattern has emerged. There was an increase in the amount of photons absorbed (ABS/RC), in dissipated (DIO/RC) and trapped (TRO/RC) energy in the photosystem II reaction centers, along with a decreased of the maximum photosystem II quantum yield (FV/FM) and electron transport per reaction center (ETO/RC). The EC50 and LOEC values for growth and photosynthesis were calculated and established that growth was the most affected parameter by glyphosate-based herbicide, while parameter TRO/RC was the least affected. All species showed reduced growth at glyphosate concentrations lower than the Canadian standard for the protection of aquatic life, set at 800µgl-1 or the American aquatic life benchmark for acute toxicity in non vascular plants of 12 100µgl-1 questioning the validity of these thresholds in assessing the risks related to the presence of glyphosate and glyphosate-based herbicides in aquatic systems.

Herbaceous or Salix miyabeana 'SX64' narrow buffer strips as a means to minimize glyphosate and aminomethylphosphonic acid leaching from row crop fields.

Glyphosate is the most widely used herbicide worldwide and is now frequently detected in surface waters of agricultural regions, notably in Quebec (Canada). Numerous legislations require vegetated riparian buffer strips (RBS) along agricultural streams. Quebec policy requires 3-meter-wide RBS. The present study evaluates the efficiency of narrow herbaceous and low- or high-density (33,333 and 55,556stumps/ha) willow, Salix miyabeana 'SX64', RBS, to minimize leaching of glyphosate and its main degradation product (AMPA) from agricultural fields to streams. Our study compared triplicate treatments of herbaceous and willow-planted RBS located in an organic-rich soil at Boisbriand (BB) and in a mineral soil at Saint-Roch-de-l'Achigan (SR). Runoff water was sampled with surface collectors and interstitial water was collected with 35cm or 70cm tension lysimeters. Potential efficiency of the RBS is reported as the percent reduction between edge-of-field and edge-of-stream concentrations in runoff and interstitial waters. Neither glyphosate nor AMPA in runoff were significantly intercepted by the RBS. After field herbicide spraying, glyphosate measured in SR surface soils (0-20cm) was on average 210µg·kg-1 dw (range from undetected to ≤317µg·kg-1 dw). Glyphosate was found to be persistent and its infiltration towards groundwater may be enhanced by the RBS. Contrary to runoff trends, soil glyphosate was significantly less concentrated on the SR edge-of-stream compared to edge-of-field (27-54% potential efficiency). The potential efficiency of herbaceous, low- and high-density willow RBS were undifferentiated.

Left ventricular assist pump pocket infection: conservative treatment strategy for destination therapy candidates.

BACKGROUND: Heart failure is a major cause of mortality and morbidity, particularly among patients with advanced disease and no access to cardiac transplantation. LVAD implantation is not only a bridge-to-transplantation option for patients awaiting a heart donor, but is often used as bridge-to-destination therapy in patients unsuited for transplantation for various reasons. LVAD infection is considered the second-most common cause of death in patients who survive the initial 6 months on LVAD support. Few reports describe the indications for chronic suppressing antibiotic therapy, device exchange, methods for exchanging infected devices, post-exchange antimicrobial management status, and the outcomes of such patients. CASE PRESENTATION: This is the case of a 74-year-old male patient with numerous comorbidities who received urgent surgical management for severe heart failure with a HeartMate II. Six months later he developed an LVAD pump infection with methicillin-resistant Staphylococcus epidermidis, which was diagnosed with leucocyte scintigraphy. The patient received an omental graft over the LVAD and a chronic suppressive antibiotic regime. A marked leukocyte scintigraphy showed the infection's regression 6 months after the initiation of antibiotic treatment. DISCUSSION: We concisely reviewed the driveline infections and the main aspects of the LVAD pump infection. We reviewed options for conservative and nonconservative management and showed that conservative management of the LVAD pump infection is possible. CONCLUSIONS: There are no defined recommendations for the management of LVAD pump infection. This case is among the few in the literature showing that conservative treatment of an LVAD pump infection is possible.

Anatomical features of acute mitral valve repair dysfunction: Additional value of three-dimensional echocardiography.

Recurrence of mitral regurgitation after mitral valve repair is correlated with unfavourable left ventricular remodelling and poor outcome. This pictorial review describes the echocardiographic features of three types of acute mitral valve repair dysfunction, and the additional value of three-dimensional echocardiography.

Is Transesophageal Echocardiography Needed before Hospital Discharge in Patients after Bentall Surgery?

BACKGOUND: Whether transesophageal echocardiography (TEE) should be routinely performed before hospital discharge after Bentall surgery remains unclear. The investigators took advantage of this practice at their institution to evaluate its benefit. METHODS: All patients who had undergone the Bentall procedure at Bichat Hospital from January 2010 to March 2014 were included. For each patient, transthoracic echocardiographic and transesophageal echocardiographic data and clinical events were retrospectively collected from the various reports. RESULTS: One hundred ninety-eight patients underwent the Bentall procedure during the study period. Postoperative TEE was performed in 117 patients (59.1%), including nine with abnormalities observed on transthoracic echocardiography (a vibrating element on the new prosthetic valve, suspicion of peritubular complications in two patients, and aortic regurgitation in six patients). In 108 patients, routine TEE was performed (i.e., without clinical indication beyond baseline postoperative imaging). Patients with and those without routine TEE were identical, except for more frequent endocarditis as an indication for surgery in patients with routine TEE. Routine TEE did not reveal any new findings that prior transthoracic echocardiography had not shown. The most frequent finding on transthoracic echocardiography or TEE was periaortic hematoma, which sometimes led to the performance of computed tomography. This imaging did not change the care of the patients in this population. CONCLUSIONS: This study does not support the performance of TEE after Bentall surgery during the in-hospital course in the absence of a specific indication. Baseline postoperative imaging using TEE or computed tomography should preferably be recommended beyond the early postoperative period after periaortic hematoma has resolved.

Presentation, management and outcome of heparin-induced thrombocytopenia after valvular heart surgery.

OBJECTIVES: The use of heparin exposes patients to heparin-induced thrombocytopenia, which is a challenging issue for both diagnosis and patient management. We sought to describe the clinical presentation, management and outcome of a series of patients diagnosed with heparin-induced thrombocytopenia after heart valve surgery. METHODS: All consecutive patients diagnosed with heparin-induced thrombocytopenia during the postoperative period of heart valve surgery over a 6-year period were prospectively enrolled in a single-centre registry. Clinical and biological data were collected. In-hospital and mid-term outcomes were assessed. Information regarding the occurrence of all medical events including death, recurrence of thromboembolic events and/or thrombocytopenia was collected. RESULTS: We identified 93 patients (incidence proportion = 2.8%). Most patients (82%) were asymptomatic with isolated thrombocytopenia at the time of diagnosis. The other main circumstance of diagnosis was the occurrence of thromboembolic events in 17 patients (6 strokes, 10 prosthetic valve thrombosis and 1 peripheral embolic event). The in-hospital mortality rate was 1%. No thrombolysis, interventional procedure or redo surgery was performed. Danaparoid sodium was used as heparin replacement therapy in most cases (96%) and leading to complete and uneventful thrombus resolution in all cases with only one possibly related major bleeding complication. During a mean follow-up of 36 ± 20 months, no patient presented recurrence of any heparin-induced thrombocytopenia-related complication. CONCLUSIONS: In this contemporary series of patients, heparin-induced thrombocytopenia incidence was low and isolated thrombocytopenia was the most frequent presentation. Conservative management with early diagnosis and substitutive anticoagulation therapy introduction was associated with a low rate of clinical events and a remarkably good outcome with a low mortality rate.

Endocarditis due to gram-negative bacilli at a French teaching hospital over a 6-year period: clinical characteristics and outcome.

BACKGROUND: Infective endocarditis (IE) due to gram-negative bacilli (GNB) is rare. However, several studies described a change in the epidemiological profile of patients within the past few years. METHODS: We reviewed all cases diagnosed and followed in the infectious diseases ward of a French teaching hospital in Paris between 2009 and 2014, inclusive. RESULTS: Among the 17 patients with definite GNB-IE (11 male, mean age 54 years), 12 (70%) were due to non-HACEK GNB and 5 (30%) to HACEK group GNB. A prosthetic valve was involved in 10 cases (8 in non-HACEK and 2 in HACEK group). Escherichia coli (4/12 patients) and Pseudomonas aeruginosa (3/12 patients) were the most common pathogens in the first group; all the pathogens in the second group were Haemophilus spp. One-third of the patients with non-HACEK GNB had nosocomial IE, whereas injection drug use-related infections were rare (2/12). All patients with HACEK infection had at least one complication (intracardiac abscess, stroke or other systemic embolization). All patients were treated by antibiotic combination therapy during a median time of 42 days (interquartile range (IQR) = 42-42) and 10 (59%) underwent cardiac surgery. One death at 9 months was observed in the non-HACEK group. CONCLUSIONS: Regarding HACEK IE, this report supports the frequent association with vascular complications. Regarding non-HACEK GNB IE, this report supports the increasing proportion of nosocomial infections. We reported a high proportion of surgery in the therapeutic management of both HACEK and non-HACEK groups associated with no in-hospital mortality.

Von Willebrand factor, a versatile player in gastrointestinal bleeding in left ventricular assist device recipients?

BACKGROUND: Bleeding originating in the gastrointestinal (GI) tract is one of the most common adverse events after left ventricular assist device (LVAD) implantation. In these patients, GI bleeding appears to be the consequence of altered hemostasis on the one hand and alterations of the GI microvasculature on the other. CASE REPORT: We report the case of a patient who suffered repeated, severe GI bleeding early after implantation of a HeartMate II continuous-flow LVAD. RESULTS: After failure of conventional treatment strategies, GI bleeding was controlled using repeated transfusions of a purified von Willebrand factor (VWF) concentrate, almost devoid of Factor VIII (Wilfactin, LFB). No episodes of pump thrombosis were noted. Subsequent to VWF transfusions, we observed a progressive normalization of circulating vascular endothelial growth factor levels. CONCLUSIONS: Our data raise the possibility that, in addition to its hemostatic properties, transfusions of VWF might have acted as an antiangiogenic factor.

Respective performance of 18F-FDG PET and radiolabeled leukocyte scintigraphy for the diagnosis of prosthetic valve endocarditis.

UNLABELLED: Echocardiography plays a key role in the diagnosis of infective endocarditis (IE) but can be inconclusive in patients in whom prosthetic valve endocarditis (PVE) is suspected. The incremental diagnostic value of (18)F-FDG PET and radiolabeled leukocyte scintigraphy in IE patients has already been reported. The aim of this study was to compare the respective performance of (18)F-FDG PET and leukocyte scintigraphy for the diagnosis of PVE in 39 patients. METHODS: (18)F-FDG PET and leukocyte scintigraphy were performed on 39 consecutive patients admitted because of clinically suspected PVE and inconclusive echocardiography results. The results of (18)F-FDG PET and leukocyte scintigraphy were analyzed separately and retrospectively by experienced physicians masked to the results of the other imaging technique and to patient outcome. The final Duke-Li IE classification was made after a 3-mo follow-up. RESULTS: Of the 39 patients, 14 were classified as having definite IE, 4 as having possible IE, and 21 as not having IE. The average interval between (18)F-FDG PET and leukocyte scintigraphy was 7 ± 7 d. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 93%, 71%, 68%, 94%, and 80%, respectively, for (18)F-FDG PET and 64%, 100%, 100%, 81%, and 86%, respectively, for leukocyte scintigraphy. Discrepancies between the results of (18)F-FDG PET and leukocyte scintigraphy occurred in 12 patients (31%). In patients with definite IE, 5 had true-positive (18)F-FDG PET results but false-negative leukocyte scintigraphy results. Of these 5 patients, 3 had nonpyogenic microorganism IE (Coxiella or Candida). Of patients for whom endocarditis had been excluded, 6 had true-negative leukocyte scintigraphy results but false-positive (18)F-FDG PET results. These 6 patients had been imaged in the first 2 mo after the last cardiac surgery. The last patient with a discrepancy between (18)F-FDG PET and leukocyte scintigraphy was classified as having possible endocarditis and had positive (18)F-FDG PET results and negative leukocyte scintigraphy results. CONCLUSION: (18)F-FDG PET offers high sensitivity for the detection of active infection in patients with suspected PVE and inconclusive echocardiography results. Leukocyte scintigraphy offers a higher specificity, however, than (18)F-FDG PET for diagnosis of IE and should be considered in cases of inconclusive (18)F-FDG PET findings or in the first 2 mo after cardiac surgery.

Alteration of plant physiology by glyphosate and its by-product aminomethylphosphonic acid: an overview.

It is generally claimed that glyphosate kills undesired plants by affecting the 5-enolpyruvylshikimate-3-phosphate synthase (EPSPS) enzyme, disturbing the shikimate pathway. However, the mechanisms leading to plant death may also be related to secondary or indirect effects of glyphosate on plant physiology. Moreover, some plants can metabolize glyphosate to aminomethylphosphonic acid (AMPA) or be exposed to AMPA from different environmental matrices. AMPA is a recognized phytotoxin, and its co-occurrence with glyphosate could modify the effects of glyphosate on plant physiology. The present review provides an overall picture of alterations of plant physiology caused by environmental exposure to glyphosate and its metabolite AMPA, and summarizes their effects on several physiological processes. It particularly focuses on photosynthesis, from photochemical events to C assimilation and translocation, as well as oxidative stress. The effects of glyphosate and AMPA on several plant physiological processes have been linked, with the aim of better understanding their phytotoxicity and glyphosate herbicidal effects.

Feasibility of percutaneous mitral commissurotomy in patients with commissural mitral valve calcification.

AIMS: Whether a percutaneous mitral commissurotomy (PMC) should be attempted in patients with mitral stenosis (MS) and valvular calcification, especially located at the commissural level remained debated. We sought to evaluate the impact of the degree and location of mitral valve calcifications on PMC results. METHODS AND RESULTS: Over a 3-year period, we enrolled 464 consecutive patients who underwent a PMC at our institution. According to the location (within the body valve leaflets' or at the commissural level) and the degree of calcification, patients were divided into three groups: 261 patients were in Group 1 (no leaflets' or commissural calcification), 141 in Group 2 (leaflets' calcification with no significant commissural calcification), and 62 in Group 3 (at least one commissure significantly calcified). Final valve area (1.83 ± 0.26, 1.71 ± 0.25, and 1.60 ± 0.24 cm(2), P < 0.00001) and the rate of complete opening of at least one commissure (92, 94, and 84%, P = 0.05) were significantly different. However, the rate of post-PMC mitral regurgitation (MR) of grade ≥ 3 (10, 10, and 8%, P = 0.90) was not different among the groups and if the rate of good immediate result, defined as valve area ≥ 1.5 cm(2) with no MR >2/4 was different among the three groups (88, 78, and 73%, P = 0.004), an overallprocedural success could be achieved in most patients with calcified commissures. CONCLUSION: In this large contemporary series of patients with MS, a procedural success was obtained less frequently in patients with calcified commissure but a successful PMC could still be safely achieved in a large proportion of patients. Our results support the use of PMC as a first-line treatment of patients with severe MS even in the presence of significant commissural calcifications with otherwise favourable clinical characteristics.

Determinants of cerebral lesions in endocarditis on systematic cerebral magnetic resonance imaging: a prospective study.

BACKGROUND AND PURPOSE: Cerebral lesions are frequent complications of infective endocarditis (IE) and have a prognostic impact. Cerebral MRI identifies lesions in a high number of patients. However, their determinants have not been identified. The aim of the study was to define the determinants of cerebral lesions in patients with IE undergoing systematic cerebral MRI. METHODS: Determinants of ischemic lesions and of microbleeds were prospectively analyzed in 120 patients with left-sided IE, using systematic cerebral MRI. RESULTS: Median age was 60 years (interquartile range 51-72); IE occurred on a prosthetic valve in 37 patients (30.8%) and was due to Streptococci in 47 patients and Staphylococci in 36; 15 (12.5%) had neurological symptoms. MRI detected ischemic lesions in 64 patients (53.3%; territorial lesions in 32 and small lesions in 57) and microbleeds in 72 (60.0%). In multivariate analysis, ischemic lesions were associated with vegetation length (odds ratio 1.10/mm; 95% confidence interval 1.03-1.16; P=0.003) and Staphylococcus aureus IE (odds ratio 2.65; 95% confidence interval 1.01-6.96; P=0.05). A vegetation length >4 mm identified ischemic lesions with a sensitivity of 74.6% and a specificity of 51.5%. Microbleeds were associated with prosthetic IE (odds ratio 8.01; 95% confidence interval 2.58-24.90; P=0.0003) and not with prior anticoagulant therapy (P=0.67). CONCLUSIONS: Systematic cerebral MRI frequently detects ischemic lesions and microbleeds during acute IE. The high sensitivity of MRI shows that each millimeter increase in vegetation length is associated with a 10% increase in the rate of ischemic lesions. Conversely, microbleeds are associated only with prosthetic IE in this study. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00144885.