Development of an in vitro model of calcified cerebral emboli in acute ischemic stroke for mechanical thrombectomy evaluation.

: ​ BACKGROUND: Calcified cerebral emboli (CCEs) are a rare cause of acute ischemic stroke (AIS) and are frequently associated with poor outcomes. The presence of dense calcified material enables reliable identification of CCEs using non-contrast CT. However, recanalization rates with the available mechanical thrombectomy (MT) devices remain low. OBJECTIVE: To recreate a large vessel occlusion involving a CCE using an in vitro silicone model of the intracranial vessels and to demonstrate the feasability of this model to test different endovascular strategies to recanalize an occlusion of the M1 segment of the middle cerebral artery (MCA). : ​ METHODS: An in vitro model was developed to evaluate different endovascular treatment approaches using contemporary devices in the M1 segment of the MCA. The in vitro model consisted of a CCE analog placed in a silicone neurovascular model. Development of an appropriate CCE analog was based on characterization of human calcified tissues that represent likely sources of CCEs. Feasibility of the model was demonstrated in a small number of MT devices using four common procedural techniques. : ​ RESULTS: CCE analogs were developed with similar mechanical behavior to that of ex vivo calcified material. The in vitro model was evaluated with various MT techniques and devices to show feasibility of the model. In this limited evaluation, the most successful retrieval approach was performed with a stent retriever combined with local aspiration through a distal access catheter, and importantly, with flow arrest and dual aspiration using a balloon guide catheter. : ​ CONCLUSION: Characterization of calcified tissues, which are likely sources of CCEs, has shown that CCEs are considerably stiffer than thrombus. This highlights the need for a different in vitro AIS model for CCEs than those used for thromboemboli. Consequentially, an in vitro AIS model representative of a CCE occlusion in the M1 segment of the MCA has been developed.

Drug-induced aortic valve stenosis: An under recognized entity.

BACKGROUND: We have been intrigued by the observation that aortic stenosis (AS) may be associated with characteristic features of mitral drug-induced valvular heart disease (DI-VHD) in patients exposed to valvulopathic drugs, thus suggesting that beyond restrictive heart valve regurgitation, valvulopathic drugs may be involved in the pathogenesis of AS. METHODS: Herein are reported echocardiographic features, and pathological findings encountered in a series of patients suffering from both AS (mean gradient >15mmHg) and mitral DI-VHD after valvulopathic drugs exposure. History of rheumatic fever, chest radiation therapy, systemic disease or bicuspid aortic valve disease were exclusion criteria. RESULTS: Twenty-five (19 females, mean age 62years) patients having both AS and typical features of mitral DI-VHD were identified. Mean transaortic pressure gradient was 32+/-13mmHg. Aortic regurgitation was ≥ mild in 24 (96%) but trivial in one. Known history of aortic valve regurgitation following drug initiation prior the development of AS was previously diagnosed in 17 patients (68%). Six patients underwent aortic valve replacement and 3 both aortic and mitral valve replacement. In the 9 patients with pathology analysis, aortic valvular endocardium was markedly thickened by dense non-inflammatory fibrosis, a characteristic feature of DI-VHD. CONCLUSION: The association between AS and typical mitral DI-VHD after valvulopathic drug exposure may not be fortuitous. Aortic regurgitation was usually associated to AS and preceded AS in most cases but may be lacking. Pathology demonstrated the potential role of valvulopathic drugs in the development of AS.

Comparison of prognoses of Staphylococcus aureus left-sided prosthetic endocarditis and prosthetic endocarditis caused by other pathogens.

BACKGROUND: Staphylococcus aureus prosthetic valve endocarditis (SAPIE) is a serious disease. AIMS: Our objective was to study the clinical, echocardiographic and prognostic characteristics of left-sided SAPIE, and to compare these characteristics with those of left-sided non-S. aureus prosthetic infective endocarditis (NSAPIE) (i.e. left-sided prosthetic infective endocarditis caused by another germ). METHODS: This was a retrospective analysis of 35 cases of SAPIE among 247 cases of left-sided prosthetic valve endocarditis hospitalized at two university hospitals (Amiens and Marseille, France). RESULTS: SAPIE accounted for 14.1% of the cases of left-sided prosthetic valve endocarditis. SAPIE complications included heart failure (in 42.8% of cases), acute renal failure (in 51.4%), sepsis (in 51.4%), neurological events (in 31.4%), systemic embolic event (in 34.2%) and abscess (in 60.0%). In-hospital mortality occurred in 48.5% of SAPIE cases compared with 16% of NSAPIE cases. A comparison of the SAPIE and NSAPIE groups showed a significant difference in terms of 4-year survival (31.8±7.3% vs 60.1±4.1%; P=0.001). Severe sepsis was the only prognostic factor associated with in-hospital mortality (odds ratio 5.7; P=0.03) and long-term mortality (odds ratio 3.7; P=0.01) in cases of SAPIE. Sepsis-induced multiple organ dysfunction syndrome was the main cause of in-hospital mortality (70.5%). CONCLUSIONS: SAPIE is a very serious disease, with elevated in-hospital mortality resulting from sepsis-induced multiple organ dysfunction syndrome. Emergency surgery is recommended in these cases, when possible, before the occurrence of complications, especially severe sepsis.

Haemodynamic performance of the small supra-annular Trifecta bioprosthesis: results from a French multicentre study.

OBJECTIVES: The St Jude Medical Trifecta bioprosthesis incorporates a single pericardial sheet externally mounted on a titanium stent that provides excellent haemodynamic results. The purpose of this multicentre study was to report on the haemodynamic performance and the expected lower risk of prosthesis-patient mismatch in patient with small aortic annulus diameters. METHODS: The 19- and 21-mm Trifecta valves were implanted in 88 and 266 eligible patients, respectively between 2011 and 2013 at three centres in France (Angers, Rennes and Amiens). The mean age of the population was 78 ± 7 and 76 ± 6 years for 19- and 21-mm valve sizes of which 96.6 and 68% were female, respectively. The aortic valve replacement was associated with another surgery in 18.2 and 21.8% in each group, respectively. RESULTS: The mean follow-up was 20.3 ± 11.9 and 24 ± 11.4 months for 19- and 21-mm valves, respectively. Early all-cause mortality was 2.5% and late mortality occurred in 5.8% of patients. The mean pressure gradient and the effective orifice area at discharge and at 1 year were respectively 12.4 ± 4.6 and 14.7 ± 5.8 mmHg (P = 0.003), 1.5 ± 0.3 and 1.4 ± 0.9 cm(2) (P = 0.06) in the 19-mm valve group; 10.4 ± 3.8 and 11.7 ± 4.5 mmHg (P = 0.001), 1.8 ± 0.3 and 1.5 ± 0.4 cm(2) (P = 0.1) in the 21-mm valve group. At 1 year, only 38 (11%) and 28 (8.1%) patients presented a moderate or severe prosthesis-patient mismatch for the two groups. After univariate analysis, no risk factor of mismatch was found. CONCLUSIONS: The 19- and 21-mm St Jude Medical Trifecta provide excellent haemodynamic performance and the rate of moderate and severe prosthesis-patient mismatch is low.

Long-term prognosis of left-sided native-valve Staphylococcus aureus endocarditis.

BACKGROUND: Staphylococcus aureus infective endocarditis (SAIE) is a serious and common disease. AIMS: To assess the clinical and echocardiographic characteristics and prognostic factors of left-sided native-valve SAIE, and to compare these characteristics between two periods (1990-2000 vs. 2001-2010). METHODS: This was a retrospective analysis of 162 cases of left-sided native-valve SAIE among 1254 patients hospitalized for infective endocarditis (IE) between 1990 and 2010. RESULTS: SAIE represented 18.1% of all cases of IE and 22.9% of cases of native-valve IE. Complications included heart failure in 44.7% of cases, acute renal failure in 23.3%, sepsis in 28.5%, neurological events in 35.8%, systemic embolic events in 54.9% and in-hospital mortality in 25.3%. Factors associated with in-hospital mortality were heart failure (odds ratio [OR] 2.5; P=0.04) and sepsis (OR 5.3; P=0.001). Long-term 5-year survival was 49.6±4.9%. Factors associated with long-term mortality were heart failure (OR 1.7; P=0.032), sepsis (OR 3; P=0.0001) and delayed surgery (OR 0.43; P=0.003). Comparison of the two periods revealed a significant increase in bivalvular involvement, valvular incompetence and acute renal failure from 2001 to 2010. No significant difference was observed in terms of in-hospital mortality rates (28.1% vs. 23.5%; P=0.58) and long-term 5-year survival (45.0±6.6% vs. 57.1±6.4%; P=0.33). CONCLUSION: Mortality as a result of left-sided native-valve SAIE remains high. Factors associated with in-hospital mortality are heart failure and sepsis. Factors associated with long-term mortality are heart failure, sepsis and delayed surgery. Despite progress in surgical techniques, in-hospital mortality and long-term mortality have not decreased significantly between the two periods.

Valvular heart disease associated with long-term treatment by methysergide: a case report.

This case report concerns a woman treated continuously since at least 10 years by methysergide for cluster headache. The echocardiographic and histological features of the severe valve fibrosis presented by this patient are very similar to those described with 5 HT(2B) receptors agonistic drugs.

Hemodynamic performance during exercise of the new St. Jude Trifecta aortic bioprosthesis: results from a French multicenter study.

BACKGROUND: Initial experience with the new St. Jude Trifecta pericardial aortic stented bioprosthesis shows an excellent resting hemodynamic profile. Little is known about changes in the hemodynamic profile of the Trifecta valve during exercise. METHODS: Between February 2011 and November 2012, 85 patients (49 men; mean age, 76 ± 7 years) with severe symptomatic aortic stenosis who underwent aortic valve replacement with the Trifecta bioprosthesis at three centers in France (Amiens, Rennes, and Angers) underwent quantitative Doppler echocardiographic at rest, during low-level exercise (25 W), and during peak exercise (68 ± 21 W), 6 months after aortic valve replacement. RESULTS: Mean peak transvalvular aortic velocity, mean transvalvular gradient, and mean left ventricular ejection fraction for all valve sizes were 211 ± 35 cm/sec, 10 ± 3 mm Hg, and 62 ± 10% at rest; 237 ± 48 cm/sec, 13 ± 4 mm Hg, and 64 ± 10% during low-level exercise; and 248 ± 70 cm/sec, 15 ± 5 mm Hg, and 67 ± 10% during peak exercise, respectively. Mean effective orifice area was 1.84 ± 0.42 cm(2) at rest, 1.86 ± 0.84 cm(2) (P = .92) during low-level exercise, and 1.95 ± 0.62 cm(2) (P = .49) during peak exercise. The prevalence of prosthesis-patient mismatch was low in the overall series (23%) and increased to 30% for the smallest valve sizes (19 and 21 mm). CONCLUSIONS: The new Trifecta bioprosthesis provides an excellent hemodynamic profile both at rest and during exercise. This type of valve could be an appropriate choice in patients with small aortic annular diameters, to avoid prosthesis-patient mismatch.

Prediction of symptomatic embolism in infective endocarditis: construction and validation of a risk calculator in a multicenter cohort.

OBJECTIVES: The aim of this study was to develop and validate a simple calculator to quantify the embolic risk (ER) at admission of patients with infective endocarditis. BACKGROUND: Early valve surgery reduces the incidence of embolism in high-risk patients with endocarditis, but the quantification of ER remains challenging. METHODS: From 1,022 consecutive patients presenting with definite diagnoses of infective endocarditis in a multicenter observational cohort study, 847 were randomized into derivation (n = 565) and validation (n = 282) samples. Clinical, microbiological, and echocardiographic data were collected at admission. The primary endpoint was symptomatic embolism that occurred during the 6-month period after the initiation of treatment. The prediction model was developed and validated accounting for competing risks. RESULTS: The 6-month incidence of embolism was similar in the development and validation samples (8.5% in the 2 samples). Six variables were associated with ER and were used to create the calculator: age, diabetes, atrial fibrillation, embolism before antibiotics, vegetation length, and Staphylococcus aureus infection. There was an excellent correlation between the predicted and observed ER in both the development and validation samples. The C-statistics for the development and validation samples were 0.72 and 0.65, respectively. Finally, a significantly higher cumulative incidence of embolic events was observed in patients with high predicted ER in both the development (p < 0.0001) and validation (p < 0.05) samples. CONCLUSIONS: The risk for embolism during infective endocarditis can be quantified at admission using a simple and accurate calculator. It might be useful for facilitating therapeutic decisions.

Predicting left ventricular dysfunction after valve repair for mitral regurgitation due to leaflet prolapse: additive value of left ventricular end-systolic dimension to ejection fraction.

AIMS: Left ventricular (LV) dysfunction is the first cause of late mortality after mitral valve surgery. In this retrospective analysis, we studied the association between preoperative echocardiographic LV measures and occurrence of LV dysfunction after mitral valve repair (MVR). METHODS AND RESULTS: Between 1991 and 2009, 335 consecutive patients underwent MVR for severe mitral regurgitation due to leaflet prolapse in our institution. Echocardiography was performed preoperatively and at 10.8 (9.1-12.0) months after surgery in 303 patients who represented the study population. Cardiac events were recorded during follow-up. LV ejection fraction (EF) decreased from 68 ± 9% before surgery to 59 ± 9% post-operatively (P < 0.001). Preoperative EF <64% and LV end-systolic diameter (ESD) ≥ 37 mm were the best cut-off values for the prediction of post-operative LV dysfunction (EF < 50%). On the basis of a combined analysis, the occurrence of post-operative LV dysfunction was 9% when EF was ≥ 64% and LVESD < 37 mm, 21% with EF < 64% or LVESD ≥ 37 mm, and 33% with EF < 64% and LVESD ≥ 37 mm (P for trend < 0.001). The combined variable EF < 64% and LVESD ≥ 37 mm added incremental prognostic value to the multivariable regression model (P = 0.001). CONCLUSION: Simple preoperative echocardiography measures allow the prediction of LV dysfunction after MVR in patients with leaflet prolapse. Patients with preoperative EF ≥ 64% and LVESD < 37 mm incur relatively low risk of post-operative LV dysfunction.

Heart failure in left-sided native valve infective endocarditis: characteristics, prognosis, and results of surgical treatment.

AIMS: Although congestive heart failure (CHF) represents the most common cause of death in native valve infective endocarditis (IE), recent data on the outcome of IE complicated by CHF are lacking. We aimed to analyse the characteristics and prognosis of patients with left-sided native valve IE complicated by CHF and to evaluate the impact of early surgery on 1 year outcome. METHODS AND RESULTS: Two hundred and fifty-nine consecutive patients with definite left-sided native valve IE according to the Duke criteria were included in this analysis. When compared with patients without CHF (n = 151), new heart murmur, high comorbidity index, aortic valve IE, and severe valve regurgitation were more frequently observed in CHF patients (n = 108, 41.6%). Mitral valve IE, embolic events and neurological events were less frequent in CHF patients. Congestive heart failure was independently predictive of in-hospital [OR 3.8 (1.7-9.0); P = 0.0013] and 1 year mortality [HR 1.8 (1.1-3.0); P = 0.007]. Early surgery was performed in 46% of CHF patients with a peri-operative mortality of 10%. In the CHF group, comorbidity index, Staphylococcus aureus IE, uncontrolled infection, and major neurological events were univariate predictors of 1 year mortality. Early surgery was independently associated with improved 1 year survival [HR 0.45 (0.22-0.93); P = 0.03]. CONCLUSION: Left-sided native valve IE complicated by CHF is more frequent in aortic IE and is associated with severe regurgitation. Congestive heart failure is an independent predictor of in-hospital and 1 year mortality. In CHF patients, early surgery is independently associated with reduced mortality and should be widely considered to improve outcome.

Infective endocarditis in elderly patients: clinical characteristics and outcome.

BACKGROUND: The aim of this study was to describe a single unit experience for the treatment of acute infective endocarditis, for patients older than 75 years and to analyse the results of early surgery. PATIENTS AND METHODS: From January 1991 to June 2006 348 consecutive patients with definite acute infective endocarditis, according to Duke criteria, were prospectively enrolled in our database. Among these, 75 patients older than 75 years (mean age 79.8+/-4 years) were analysed and compared to 273 younger patients. RESULTS: The patients older than 75 years (group A, 75 patients) had a more severe clinical status than the younger patients (group B, 273 patients) with a comorbidity index amounting to 4.9+/-1.8 and 2.9+/-1.0 respectively (p=0.0001). Patients were treated medically (group A 53 pts vs group B 124 pts) or surgically (group A 22 pts vs group B 149 pts) (p=0.001). The in-hospital mortality rate for group A and B was comparable (16% vs 19%; p=0.3). Multivariate analysis identified for patients older than 75 years, severe sepsis (p=0.001, OR=12, CI [6-24]), and major neurological events (p=0.02, OR=3, CI [1.1-7.5]) as the two factors related to higher in-hospital mortality and surgery (p=0.006, OR=0.4, CI [0.2-0.7]) as the factor related to a lower in-hospital mortality. The overall survival of the older group at 36 months was 40.8+/-6.8%. Multivariate analysis for older patients identified comorbidity index (p=0.001) (HR 1.1, CI [1-1.2]), severe sepsis (p=0.0001) (HR 3.3, CI [2.2-5.2]), valvular prosthesis (p=0.0002) (HR 2.4, CI [1.5-4]) and major neurological event (p=0.04) (HR 1.7, CI [1-3]) as factors related to overall mortality and surgery (p=0.001) (HR 0.4, CI [0.3-0.6]) as a factor related to a better overall survival. CONCLUSION: The immediate results of treatment for endocarditis are comparable between elderly and younger patients. The long-term prognosis for the elderly patients is worse, mainly related to a higher comorbidity index. Surgery in elderly patients may be a reasonable option, and should be considered in selected elderly patients.

Septic coronary embolism in aortic valvular endocarditis.

Acute myocardial infarction due to septic coronary emboli in active infective endocarditis is rare, but may be fatal. The case is reported of a 58-year-old man who presented with wrist arthritis, which resulted in acute aortic valvular endocarditis. Echocardiography revealed 3 mm vegetations on the posterior and anterior valve cusps, and aortic regurgitation (grade 3-4). As the patient's clinical status was stable, medical treatment was selected which included antibiotic therapy, but after four weeks the patient reported an acute anterior chest pain. Coronary angiography revealed stenosis of the left anterior descending (LAD) artery, due to septic embolism. The patient was referred for emergency cardiac surgery, at which a surgical thrombectomy and coronary artery bypass grafting with reconstruction of the LAD artery were performed, along with aortic valve replacement using a bioprosthesis. The postoperative course was uneventful and the patient was discharged on postoperative day 15. An adapted oral antibiotherapy was continued for a further six-week period.