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Valvular heart disease (VHD) is the next epidemic in the cardiovascular field, affecting millions of people worldwide and having a major impact on health care systems. With aging of the population, the incidence and prevalence of VHD will continue to increase. However, VHD has not received the attention it deserves from both the public and policymakers. Despite important advances in the pathophysiology, natural history, management, and treatment of VHD including the development of transcatheter therapies, VHD remains underdiagnosed, identified late, and often undertreated with inequality in access to care and treatment options, and there is no medication that can prevent disease progression. The present review article discusses these gaps in the management of VHD and potential actions to undertake to improve the outcome of patients with VHD.

Background Transcatheter mitral valve implantation (TMVI) is a new treatment option for high-risk surgical patients with degenerated bioprosthesis (ViV), failed annuloplasty rings (ViR) and severe mitral annular calcification (ViMAC). However, limited data exist on transcatheter heart valve thrombosis. Purpose The aim of this study was to report the incidence, clinical impact and treatment outcomes of transcatheter heart valve (THV) thrombosis in patients undergoing TMVI. Methods All consecutive patients undergoing TMVI in our center between July 2010 and September 2019 were included. A transoesophageal echocardiography and a computed tomography (CT) were performed before hospital discharge and at each clinical visit, at 3 months, at 1 year and yearly after. THV thrombosis was defined as the presence of at least one thickened leaflet with restricted motion suggestive of thrombus confirmed by TOE and/or contrast CT. All patients received anticoagulation therapy with vitamin K antagonists (VKA) and a low dose of aspirin for the first 3 months. Results A total of 132 patients underwent TMVI (62 ViV, 36 ViR and 34 ViMAC). Among them, 16 (12.1%) patients had a THV thrombosis. Median age was 67 years old and 56.2% of patients were women. Median time to diagnosis of THV thrombosis was 78 days. Early THV thrombosis was observed in 7 (43.7%) and in 13 (81.2%) patients THV thrombosis occurred within the first 6 months after the procedure. 8 out 9 patients with subacute or late THV thrombosis were not anticoagulated or with subtherapeutic anticoagulation. No stroke or thromboembolic events occurred in these patients. No change in mitral gradient was observed in 14 out 16 patients. VKA were indicated in all patients. THV thrombosis resolved in all but one patient. Conclusion THV thrombosis is frequent after TMVI, occurs mainly within the first 6-months after the procedure, are mostly subclinical and resolves after optimization of anticoagulation treatment. An anticoagulation therapy for at least 6 months may be necessary. Timing of THV thrombosis Funding Acknowledgement Type of funding source: None

Background The growing use of surgical bioprostheses raises concerns about a future reoperation for bioprosthesis degeneration. There are few data on outcome after transcatheter mitral valve-in-valve implantation (TMVI) compared with redo surgical mitral valve replacement (SMVR). Purpose To compare the feasibility, safety and outcomes of TMVI versus SMVR for degenerated mitral bioprosthesis in high-risk patients. Methods In our institution, 52 patients underwent TMVI by transseptal approach and 33 SMVR for degenerated mitral bioprosthesis. The composite endpoint of event-free survival included cardiovascular mortality, stroke, major bleeding, hospitalization for heart failure or mitral valve reintervention. Results Mean age and EuroSCORE II were higher in TMVI group vs. SMVR group (age 63±21 years vs. 51±15 years, p=0.002; EuroSCORE II 12.5±12.2% vs. 6.2±3.3%, p=0.001) (Table). In-hospital mortality was 3.8% after TMVI vs. 3.0% after SMVR (p=1.0). Median follow-up was 2.2 years. At 5 years, survival was 69.7±9.4% after TMVI vs. 86.6±7.6% after SMVR (p=0.10) and event-free survival was lower after TMVI (40.1±9.9% vs 78.7±8.8% respectively, p=0.003) (Figure). In multivariate analysis, older age (p=0.02), neurologic history (p=0.05) and non-elective procedure (p Conclusion TMVI is an alternative to SMVR in high-risk patients with degenerated mitral bioprosthesis. Comparison of mid-term results of the two techniques must take into account the differences in patient characteristics. Event-free survival Funding Acknowledgement Type of funding source: None

Risk stratification as well as treatment decision in asymptomatic patients with isolated severe aortic stenosis (AS) is matter of ongoing debate. It has been known that gender-specific difference in left ventricular reaction to AS exists. Female gender has also been linked to increased risk of adverse events after surgical AVR but with better outcome after TAVI. We investigated whether there is a gender difference in functional capacity in asymptomatic patients with isolated severe AS. Asymptomatic patients with severe AS were prospectively enrolled and underwent cardiopulmonary stress-echocardiography exercise testing (ESE-CPET) on supine ergobicycle, ramp protocol, 15 W/min. Patients with ischemia positive test were excluded (ECG and/or echo) There were 139 patients, 61 women. There were no gender differences in age (66.36 vs 67.37, p=ns), echo parameters (Vmax 4.54 vs 4.48m/s, AVA 0.62 vs 0.68cm2, and Pmean 52.6 vs 53.8mmHg, all p=ns), LVEF (68.56 vs 70.90%, p=ns), e/E' (12.74 vs 14.45, p=ns), BNP (112.51 vs 110.55 pg/ml, p=ns) and valvulo-arterial impedance (4.65 vs 5.14mm Hg·ml–1·m2, p=0.07). Women had higher body mass index (29.05 vs 26.95, p=0.022), lower VO2max (12.96 vs 17.93 ml/kg/m2, p=0.001) and higher VE/VCO2 slope (33.69 vs 29.01, p=0.003). Univariable and multivariable linear regression analysis were used to test the relation between various clinical and echocardiographic parameters and VO2max. The variables independently associated with the VO2max are shown in table 1, with female gender being the strongest independent predictor of VO2max Conclusion Female gender is independent predictor of decreased functional capacity, even when adjusting for other variables, including BMI and echo markers of AS severity. Further studies are needed to determine whether this finding affects the course and outcome of the disease Funding Acknowledgement Type of funding source: None

Background Little is known about the characteristics of infectious endocarditis (IE) in cancer patients, although their risk may be higher and their presentation non-specific. Purpose This study sought to assess the prevalence of cancer in patients with IE in the EURO-ENDO registry and to determine their baseline characteristics, management, outcomes in comparison to cancer-free patients with IE. Methods Data were collected from a prospective cohort of 3085 adult patients enrolled in 40 countries between January 2016 and March 2018 with a diagnosis of IE based on the ESC 2015 diagnostic criteria. Clinical, biological, microbiological and echocardiographic findings, use of other imaging techniques, medical therapy, complications, theoretical indications for surgery, in-hospital mortality, and 1-year mortality were analysed in IE patients with and without cancer. Results 359 (11.6%) cancer patients with IE were identified and compared with 2726 IE patients without cancer. IE was community-acquired in 225/361 (74.8%), and more often nosocomial (18.6%) in healthcare associated cases. IE was native in 209 (60.4%), prosthetic in 97 (28%) and device-related in 30 (8.7%) patients. Microorganisms involved were Enterococci in 72/303 (23.8%), methicillin-sensitive Staphylococci in 63/303 (20.8%), and Streptococcus gallolyticus in 33/303 (10.9%) patients. IE cancer patients received more long-term cortico-therapy and immunosuppressive treatment compared to cancer free IE patients (9.1% vs. 3.9%, P Cancer IE patients were more frequently treated with amoxicillin (35.8% vs. 26.3%; P=0.0002) and daptomycin (15.2% vs. 10.6%; P=0.0096), but less frequently treated with vancomycin (34.6% vs. 44.9%, P=0.0003). According to the ESC guidelines, theoretical indication for cardiac surgery was not significantly different between groups (65.5% vs. 69.8%, P=0.091), but was effectively less performed when indicated in cancer IE patients during hospitalisation (65.5% vs. 75.0%, P=0.0018). Compared to cancer-free IE patients, in-hospital and 1-year death occurred in 23.4% vs. 16.1%, P=0.006, and 35.7% vs. 23.1%, P2 mg/dL, congestive heart failure and unperformed cardiac surgery (when indicated). Conclusion We report the largest contemporary series of patients with IE and cancer. The prevalence of cancer in IE patients is common and associated with a worse outcome. Patients with IE and cancer have different clinical characteristics than the general population and should require a specific management. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Pharmacological.

Tricuspid regurgitation (TR) is a very frequent manifestation of valvular heart disease. It may be due to the primary involvement of the valve or secondary to pulmonary hypertension or to the left-sided heart valve disease (most commonly rheumatic and involving the mitral valve). The pathophysiology of secondary TR is complex and is intrinsically connected to the anatomy and function of the right ventricle. A systematic multimodality approach to diagnosis and assessment (based not only on the severity of the TR but also on the assessment of annular size, RV function and degree of pulmonary hypertension) is, therefore, essential. Once considered non-important, treatment of secondary TR is currently viewed as an essential concomitant procedure at the time of mitral (and, less frequently, aortic valve) surgery. Although the indications for surgical management of severe TR are now generally accepted (Class I), controversy persists concerning the role of intervention for moderate TR. However, there is a trend for intervention in this setting, especially at the time of surgery for left-sided heart valve disease and/or in patients with significant tricuspid annular dilatation (Class IIa). Currently, surgery remains the best approach for the interventional treatment of TR. Percutaneous tricuspid valve intervention (both repair and replacement) is still in its infancy but may become a reliable option in future, especially for high-risk patients with isolated primary TR or with secondary TR related to advanced left-sided heart valve disease.

Background Contemporary and unbiased information regarding the surgical management of patients with mitral regurgitation (MR) at the Nationwide level are scarce. The PMSI, a mandatory administrative database, offers the unique opportunity to assess the presentation and outcomes of all consecutive mitral valve (MV) surgeries performed in France in the contemporary era. Methods We collected all (isolated or combined) MV surgeries performed for MR in France both in public and private hospitals between 2014 and 2016. Based on an algorithm we developed, MR etiology was classified as degenerative (DMR), secondary (SMR) or OTHER (rheumatic, congenital, infective endocarditis or unknown). Results Between January 2014 and December 2016, 18,167 mitral valve surgeries were performed in France (55% repair and 45% replacement; 52% isolated MV surgery). Mean age was 66±12 years and 59% were male. Etiology was DMR in 42%, SMR in 16% and OTHER in 42%. Among DMR, repair rate was 68% overall and 72% in the subset who underwent an isolated MV surgery (70% of all DMR). Repair rates decreased with age, Charlson index and sex (female) (all P Conclusion In this large administrative contemporary nationwide database, 1) DMR surgery was twice as frequent as SMR and more frequently performed isolated; 2) Repair rates in DMR were suboptimal overall but more critically in the elderly and women subsets. 3) Operative mortality and one-year rate of death and readmission were approximately twice as high in SMR than in DMR and overall considerable even for isolated DMR surgery; and 4) In DMR, center volume had no impact on repair rate but an independent impact on outcome. These results underline the need to develop strategies to improve management and outcomes of patients with both degenerative and secondary MR.

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.

Transcatheter aortic valve implantation (TAVI) has spawned the evolution of novel catheter-based therapies for a variety of cardiovascular conditions. Newer device iterations are delivering lower peri- and early post-procedural complication rates in patients with aortic stenosis, who were otherwise deemed too high risk for conventional surgical valve replacement. Yet beyond the post-procedural period, a considerable portion of current TAVI recipients fail to derive a benefit from TAVI, either dying or displaying a lack of clinical and functional improvement. Considerable interest now lies in better identifying factors likely to predict futility post-TAVI. Implicit in this are the critical roles of frailty, disability, and a multimorbidity patient assessment. In this review, we outline the roles that a variety of medical comorbidities play in determining futile post-TAVI outcomes, including the critical role of frailty underlying the identification of patients unlikely to benefit from TAVI. We discuss various TAVI risk scores, and further propose that by combining such scores along with frailty parameters and the presence of specific organ failure, a more accurate and holistic assessment of potential TAVI-related futility could be achieved.

Anti-thrombotic therapy after valve replacement encompasses a number of different situations. Long-term anticoagulation of mechanical prostheses uses vitamin K antagonists with a target international normalized ratio adapted to the characteristics of the prosthesis and the patient. The association of low-dose aspirin is systematic in the American guidelines and more restrictive in the European guidelines. Early heparin therapy is frequently used early after mechanical valve replacement, although there are no precise recommendations regarding timing, type, and dose of drug. Direct oral anticoagulants are presently contraindicated in patients with mechanical prosthesis. The main advantage of bioprostheses is the absence of long-term anticoagulant therapy. Early anticoagulation is indicated after valve replacement for mitral bioprostheses, whereas aspirin is now favoured early after bioprosthetic valve replacement in the aortic position. Early dual antiplatelet therapy is indicated after transcatheter aortic valve implantation, followed by single antiplatelet therapy. However, this relies on low levels of evidence and optimization of anti-thrombotic therapy is warranted in these high-risk patients. Although guidelines are consistent in most instances, discrepancies and the low-level of evidence of certain recommendations highlight the need for further controlled trials, in particular with regard to the combination of antiplatelet therapy with oral anticoagulant and the early post-operative anti-thrombotic therapy following the procedure.

This editorial refers to ‘Sex-related differences in calcific aortic stenosis: correlating clinical and echocardiographic characteristics and computed tomography aortic valve calcium score to excised aortic valve weight’[†][1], by J.J. Thaden et al ., on page 693. Aortic stenosis (AS) is the most frequent heart valve disease in industrialized countries when considering patients referred to hospital.1 Its prevalence sharply increases with age, and the number of cases is expected to double in the next 50 years due to population ageing and the lack of effective prevention strategies.2 Following advances in knowledge of its pathophysiology, prevention initially targeted the early process of the development of AS, which shares common risk factors and metabolic pathways with atherosclerosis.3 This approach was not successful, and consistent findings from all prospective, randomized trials showed that the use of statins did not slow the progression of AS.3 One of the explanations is probably that patients included in these trials already had substantial calcium burden which was unlikely to be reversed. It remains possible that statins could be effective in aortic sclerosis, which is the early stage of calcific aortic valve disease before obstruction occurs. Nevertheless, strategies of prevention dedicated to AS would raise practical problems inherent in the need for massive screening because of its high prevalence. There is now growing interest in the mechanisms involved in the valve … [1]: #fn-2

This editorial refers to ‘Management and outcomes in patients with moderate or severe functional mitral regurgitation and severe left ventricular dysfunction’, by Z. Samad et al ., on page doi:10.1093/eurheartj/ehv343. The management of patients with severe secondary (also called functional) mitral regurgitation (MR) and left ventricular (LV) dysfunction is a topic of interest because it concerns many patients who have a poor prognosis,1–3 and the data currently available on the impact of different treatments are somewhat discordant.4–9 Therefore current recommendations for interventions in both the European and US guidelines are restrictive, with a low level of evidence.10–13 The study by Samad is an important one in the field.14 The study population results from the merging of two large databases from Duke University putting together a record of 1441 patients with moderate to severe functional MR and LV dysfunction. The first goal of this contemporary study was to describe current practices. It confirmed that medical management is the most popular strategy, which was used in 75% of patients. Percutaneous coronary intervention was used in 8%, coronary bypass surgery (CABG) in 6%, CABG plus mitral valve surgery in 7%, and finally mitral valve surgery in isolation in 4% of cases. This is the basis for the choice of medical treatment as a comparator with MitraClip …

Aims In patients with a suspicion of prosthetic valve endocarditis (PVE), detection of perivalvular infection can be difficult based only on echocardiography. The aim of this retrospective study was to test the interest of radiolabelled leucocyte scintigraphy (LS) for the detection of perivalvular infection in patients with a suspicion of PVE and inconclusive transoesophageal echocardiography (TEE). Methods and results LS was performed in 42 patients. The results of LS were classified as positive in the cardiac area (intense or mild), or negative. Macroscopical aspects and bacteriology were obtained from patients who underwent cardiac surgery ( n = 10). Clinical outcome was collected in patients treated medically ( n = 32). Among patients with intense signal with LS who underwent surgery ( n = 6), five had an abscess confirmed during intervention and one, post-operatively. Patients with intense accumulation of radiolabelled leucocytes with scintigraphy and treated medically ( n = 3) had a poor outcome: death ( n = 1); prosthetic valve dehiscence ( n = 1); and recurrent endocarditis ( n = 1). Among patients with mild activity with LS ( n = 5), one patient developed a large prosthetic valve dehiscence during the follow-up. The remaining four patients were treated medically and did not present any recurrent endocarditis after a median follow-up of 14 months. No abscess was detected in patients with negative LS who underwent surgery ( n = 4). Among the patients with negative LS treated medically ( n = 24), none presented recurrent endocarditis after a mean follow-up of 15 ± 16 months. Patient management was influenced by the results of LS in 12 out of 42 patients (29%). Conclusion This study suggests that LS is useful for the identification of perivalvular infection in patients with a suspicion of PVE and inconclusive TEE.

There is currently no medical therapy that can prevent the progression of aortic valve stenosis (AS). Recent data highlight a possible relationship between bone metabolism and AS progression but prospective data are lacking.Serum levels of calcium, phosphorus, creatinine, 25-OH vitamin D, intact parathyroid hormon (iPTH), C-terminal-telopeptide of type-1-collagen (CTX) and osteocalcin were assessed at baseline in 110 elderly patients (age ≥70 years) with at least mild AS. CTX/osteocalcin ratio was calculated as a marker of bone remodelling balance. AS severity was assessed at baseline and 1-year based on the mean gradient. Two-thirds of patients had low 25-OH vitamin D and 20% had secondary hyperparathyroidism. AS progression was not associated with age, glomerular filtration rate (GFR), calcium and phosphorus levels, calcium-phosphorus product, but significantly with iPTH, CTX/osteocalcin and vitamin D status (all P0.01). There was no correlation between iPTH and CTX/osteocalcin (R = 0.04, P = 0.70) and AS progression was associated with CTX/osteocalcin (R = 0.42, P = 0.009), but not with iPTH (R = 0.10, P = 0.55) in patients with normal vitamin D levels, whereas it was associated with iPTH (R = 0.47, P0.001) and not with CTX/osteocalcin (R = 0.04, P = 0.73) in those with low vitamin D levels, especially if mild renal insufficiency was present (R = 0.61, P0.001).In elderly patients with AS, we observed an association between AS progression and vitamin D, iPTH and CTX/osteocalcin ratio and their respective influence varied according to the vitamin D status. In patients with normal vitamin D levels, AS progression was associated with a bone resorptive balance, whereas in patients with low vitamin D levels, AS progression was associated with iPTH and secondary hyperparathyroidism, especially if mild renal insufficiency was present. These findings may have important prognostic and therapeutic implications. Trial registration information: Clinicaltrials.gov identifier number: NCT00338676, funded by AP-HP, the COFRASA study.

International audience; BACKGROUND: With an increasing prevalence of patients with valvular heart disease (VHD), a dedicated management approach is needed. The challenges encountered are manifold and include appropriate diagnosis and quantification of valve lesion, organization of adequate follow-up, and making the right management decisions, in particular with regard to the timing and choice of interventions. Data from the Euro Heart Survey have shown a substantial discrepancy between guidelines and clinical practice in the field of VHD and many patients are denied surgery despite having clear indications. The concept of heart valve clinics (HVCs) is increasingly recognized as the way to proceed. At the same time, very few centres have developed such expertise, indicating that specific recommendations for the initial development and subsequent operating requirements of an HVC are needed. AIMS: The aim of this position paper is to provide insights into the rationale, organization, structure, and expertise needed to establish and operate an HVC. Although the main goal is to improve the clinical management of patients with VHD, the impact of HVCs on education is of particular importance: larger patient volumes foster the required expertise among more senior physicians but are also fundamental for training new cardiologists, medical students, and nurses. Additional benefits arise from research opportunities resulting from such an organized structure and the delivery of standardized care protocols. CONCLUSION: The growing volume of patients with VHD, their changing characteristics, and the growing technological opportunities of refined diagnosis and treatment in addition to the potential dismal prognosis if overlooked mandate specialized evaluation and care by dedicated physicians working in a specialized environment that is called the HVC.

OBJECTIVES: Surgical aortic valve replacement in patients with previous coronary artery bypass grafting (CABG) carries a high mortality. Transcatheter aortic valve implantation (TAVI) has been shown to be successful in high risk subgroups of patients. Our goal is therefore to evaluate the impact of a history of CABG on the outcome of patients who undergo TAVI. METHODS: From October 2006 to June 2010, among the 201 patients selected to undergo TAVI, 54 (27%) had a history of CABG. Outcomes were prospectively collected. RESULTS: The 30-day outcome was not different between patients with previous CABG vs. those without, in particular as regards mortality (respectively, 5.6% vs. 10.9%; P= 0.25). Mid-term survival (mean FU: 7 ± 9 months) was not different at 2 years between patients with previous CABG vs. patients without (65.7 ± 6.2% vs. 80.0 ± 7.7% respectively; P= 0.12). In multivariate analysis, CABG was not associated with an excess mid-term mortality after TAVI. CONCLUSIONS: Previous CABG does not adversely affect outcome in patients undergoing TAVI. If confirmed by larger prospective series and ideally by a randomized trial comparing CABG vs. redo surgery, this observation might lead the heart team to consider TAVI as an attractive option in the population of high risk patients with aortic stenosis and previous CABG.

This editorial refers to ‘Percutaneous mitral valve repair with the MitraClip system: acute results from a real world setting’[†][1], by C. Tamburino et al. , on page 1382 and ‘Acute outcomes of MitraClip therapy for mitral regurgitation in high-surgical-risk patients: emphasis on adverse valve morphology and severe left ventricular dysfunction’[‡][2], by O. Franzen et al. , on page 1373 The treatment of mitral valve regurgitation (MR) is an important clinical issue as MR represents >30% of native valve diseases.1 The results of surgery, in particular valve repair, are good, which sets a high standard for future innovative interventions.2 However, some observations suggest a potential for new interventions: (i) in current practice worldwide, surgery is denied to many patients with severe MR and symptoms;3 (ii) mitral valve repair is not always used or feasible;4 and (iii) surgical risks remain high in an important percentage of contemporary patients who are elderly with co-morbidities. Two main techniques have been introduced for percutaneous mitral valve repair: the edge to edge technique and the prosthetic ring annuloplasty. The edge to edge technique mimics the surgical procedure introduced by O. Alfieri, which creates a double mitral orifice by means of a few stitches securing the two leaflets together at their mid-part5 ( Figure 1 ). This technique has been performed percutaneously using a clip (E-valve MitraClip) made of a cobalt–chromium alloy and Dacron.6 Another design involved the use of one or two sutures deployed via a catheter-based device, but this has since been abandoned.7 The initial clinical experience with the edge to edge technique is mostly from the USA, including >500 patients; however, the reports in peer-reviewed journals are only based on the first 107 cases in the EVEREST registry.8,9 In addition, 279 patients are included in the EVEREST II … [1]: #fn-1 [2]: #fn-2

Aims Evaluation of the severity of the aortic stenosis (AS) is based on echocardiographic assessment of peak velocity/mean transaortic pressure gradient (MPG) by continuous-wave Doppler and calculation of the aortic valve area (AVA) using the continuity equation. Pioneering echocardiographic studies have shown that MPG should be measured from the apical and right parasternal views using non-imaging continuous-wave Doppler transducer (NI-CWD). Nowadays, ultrasound systems are often sold without NI-CWD due, at least partially, to the improvement of two-dimensional continuous-wave Doppler transducers (2D-CWD). Whether this evolution translated into misevaluation of AS severity was uncertain. Our aim was to evaluate the additional diagnostic value of the use of NI-CWD and the right parasternal view for the evaluation of AS severity in the modern area. Methods and results We prospectively evaluated MPG and AVA using the 2D-CWD (apical view) and the NI-CWD (right parasternal view) in 100 patients (78+ 5 years, 65% male) consecutively enrolled in an ongoing prospective study. Aortic stenosis severity was graded as mild (AVA � 1.5 cm 2 ), moderate (1–1.5 cm 2 ), or severe (AVA , 1c m 2 ). Misclassification was defined as at least a one grade difference and DAVA . 0.15 cm 2 (twice the intra-observer variability). Feasibility of the 2D-CWD was 100%, MPG 20+ 13 mmHg, and AVA 1.52+ 0.45 cm 2 . Fifty-three per cent had a mild AS, 34% a moderate AS, and 13% a severe AS. Using the NI-CWD, feasibility was 85%, MPG 25+ 16 mmHg, AVA 1.33+ 0.41 cm 2 (both P , 0.005 compared with 2D-CWD). Thirty-five per cent (n = 30) had a mild AS, 46% (n = 39) a moderate AS, and 19% (n = 16) a severe AS. Using only the 2D-CWD and the apical view, 21 patients (21%) would have been misclassified: 17 as mild instead of moderate AS and 4 as moderate instead of severe AS. In those misclassified patients, MPG was 9+ 6 mmHg higher with the NI-CWD and 33% had an MPG difference .10 mmHg. Conclusion The use of the NI-CWD and the right parasternal view must be performed to evaluate AS severity, especially in case of discrepancy between symptoms and AS severity or for precise evaluation of AS progression.

One limitation for a wider use of the proximal isovelocity surface area method (PISA) for the evaluation of the mitral valve area (MVA) in patients with mitral stenosis (MS) is the requirement of an angle correction factor (angle alpha between the mitral leaflets) which cannot be obtained using the machine's built-in software and requires a manual measurement. The aim of the present study was to evaluate if the use of a fixed angle could provide an acceptable MVA estimation.In 48 patients (53 +/- 14 years, 75% female and 32% atrial fibrillation), MVA was prospectively measured by planimetry (MVA(2D)) and PISA (PISA(mes)). The angle alpha was manually measured on paper prints using a protractor. MVA(2D) was 1.38 +/- 0.56 cm(2) [0.5-2.40]. PISA(mes) (alpha = 104 +/- 13 degrees inter-quartiles 90-115) was 1.34 +/- 0.64 cm(2) [0.31-2.95] and did not differ from and correlated well with MVA(2D) (P = 0.25; r = 0.93, P0.0001). MVA estimated using the PISA method and a fixed angle value from 90 to 110 (MVA(alpha)(=90) to MVA(alpha)(=110)) progressively increased from 1.20 +/- 0.66 to 1.48 +/- 0.81 cm(2). Only MVA(alpha)(=100) (1.34 +/- 0.74 cm(2)) did not differ from and correlated well with both MVA(2D) and PISA(mes) (both P0.35 and r0.90, P0.0001).The angle formed by the mitral leaflet only slightly changes in between patients and use of a fixed angle value of 100 degrees provides an accurate estimation of the MVA by the PISA method in patients with MS. This simplification would facilitate and extend the use of the PISA as an additional method for the assessment of MS severity in routine practice.

Aims Aortic valve diseases are characterized by pathological remodelling of valvular tissue but the cellular and molecular effectors involved in these processes are not well known. The role of matrix metalloproteinase (MMP)-2, MMP-9, MMP-3, MMP-7, and tissue inhibitor of matrix metalloproteinase (TIMP)-1 and TIMP-2 are investigated here. Methods and results Histological analysis of pathological valves [aortic stenosis (AS) ( n =49), aortic regurgitation (AR) ( n =23)] and control valves ( n =8) was performed. The main tissue abnormalities (calcification, inflammatory cells, and capillaries) observed in AS were less severe or absent in AR. However, both groups of pathological valves displayed similar histological signs of extracellular matrix (ECM) remodelling. Biochemical analysis of MMPs and TIMPs (gelatin and casein zymography and ELISA) was performed on valve extracts. MMP-2 activity was not significantly different in control and pathological valves. Increases in MMP-9 and MMP-3 in AS demonstrated an inflammatory state. Finally, there was a four- to seven-fold increase of TIMP-1 in pathological valves. TIMP-1, TIMP-2, and MMP-2 were synthesized by the valvular interstitial cells in primary culture. Conclusion This study demonstrates the involvement of the MMP/TIMP system in ECM remodelling of both AS and AR. These findings provide evidence of inflammatory injury more severe in AS than in AR and involvement of mesenchymal cell response.

Aims To evaluate temporal trends in percutaneous mitral commissurotomy (PMC) in terms of changes in patient characteristics and their impact on immediate results. Methods and results From 1986 to 2001, PMC was indicated in 2773 consecutive patients. Patient characteristics and results were compared each year and linear trends were analysed. There were significant trends toward an increase in mean age (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(p{

Transcatheter aortic valve implantation (TAVI) is now recognized as a valid treatment for symptomatic aortic stenosis in patients at high risk for or contraindicated to surgery.1,2 Nevertheless, a substantial number of patients do not derive benefit from the procedure in terms of survival and/or quality of life. These futile TAVI procedures raise concerns, in particular with regards to ethical and cost-effectiveness issues.3 Randomized trials and large registries provided robust data on mortality after TAVI. However, less information is available with regards to functional capacity and quality of life, which are of utmost importance in these particular patients. This lack of information is largely due to difficulties in performing serial assessment using multidimensional approaches. The originality of the paper by Hiltrop et al .4 is based on serial standardized objective evaluations of functional capacity and quality of life using validated methods. A particularly interesting finding concerns the discrepancies between 6-min walk test and New York Heart Association (NYHA) class for assessing the impact of TAVI on functional capacity. In point of fact, 6-min walking distance improved by 3.3% at 30 days and 4.3% at 6 months, but was similar to baseline value after 24 months. Even with regards to statistically significant improvements, at 30 days and 6 months, one may question the clinical relevance of a

AIMS In mitral stenosis (MS) transvalvular flow and velocity continually change throughout diastole but for mitral valve area (MVA), flow-dependent variations (valve reserve) are unknown. These physiologic changes can be studied by the proximal isovelocity surface area (PISA) method, using the high temporal resolution of colour M-mode, essential for simultaneous measurements of flow and velocity. Hence, we aimed to validate the colour M-mode PISA method for measurement of MVA in MS and to define using this method the physiologic flow-dependent changes of MVA during diastole. METHODS AND RESULTS In 50 patients with native MS, MVA was measured by planimetry (MVA-2D), Doppler pressure half-time (MVA-PHT), and two-dimensional PISA (2D-PISA). MVA measurement by colour M-mode PISA in early diastole (M-PISA) (1.27+/-0.46 cm(2)) with rigorously timed flow and velocity measurements by continuous wave Doppler did not differ and correlated well with MVA-2D (1.29+/-0.44 cm(2), p=0.59; r=0.85, p

Aims The purposes of this study were to determine the clinical features and to identify prognostic factors of abscesses associated with infective endocarditis. Methods and Results During a 5-year period from January 1989, 233 patients with perivalvular abscesses associated with infective endocarditis were enrolled in a retrospective multicentre study. Of the patients, 213 received medical–surgical therapy and 20 medical therapy alone. No causative microorganism could be identified in 31% of cases. Sensitivity for the detection of abscesses was 36 and 80%, respectively using transthoracic and transoesophageal echocardiography. Surgical treatment consisted of primary suture of the abscess (38%), insertion of a felt aortic or mitral ring using Teflon or pericardium (42%), or debridment of the abscess cavity (20%). The 1 month operative mortality was 16%. Actuarial rates for overall survival at 3 and 27 months in operated patients were 75±10% and 59±11%, respectively. Increasing patient age, staphylococcal infection, and fistulization of the abscess were found to be independent risk factors in both 1 month and overall operative mortality. Renal failure was a risk factor predictive of operative mortality at 1 month, whereas uncontrolled infection and circumferential abscess were regarded as risk factors predictive of overall operative mortality. Conclusion The data determined prognostic factors of abscesses associated with infective endocarditis.

One hundred and fifty-five patients with isolated mitral regurgitation were referred from our cardiology department for mitral valve repair between 1972 and 1990. Men were predominant (59%), mean age was 51 years, and 61% of the patients were in NYHA class III or IV. Degenerative aetiology was predominant (65%). Surgical repair was performed according to the Carpentier techniques. Two operative deaths occurred (1.3%). The survivors were followed-up for an average of 4 years, and the rates of survival and good functional results at 11.5 years, were respectively 84.5% and 64.5%. The linearized rates of endocarditis, thromboembolic events and re-operations were respectively 0.35%, 1.54% and 2.05% pt-yrs. Residual mitral regurgitation was looked for by clinical and Doppler examination: there was no regurgitation in 55.5% of patients, mild regurgitation was found in 26%, moderate in 10.3% and severe in 8.2%. Analysis of moderate and severe residual regurgitation identified three promoting factors: rheumatic origin of the regurgitation, surgery of the anterior leaflet and time of surgery (the incidence after surgery has been lower in recent years). Other 'less well known' complications were encountered: left ventricular outflow tract obstruction, progressive evolution towards mitral stenosis, appearance of aortic regurgitation and formation of left atrial thrombi. Despite these complications, we must stress the satisfactory results of the technique, in particular in mitral valve endocarditis; 22 patients were operated on for this reason, six during the acute phase of the disease, and no surgical death, or recurrence of endocarditis, and only one case of severe residual regurgitation was observed.

The aim of this study was to assess the value of transoesophageal echo (TEE) in comparison with transthoracic echocardiography (TTE) in selecting candidates and evaluating the results of percutaneous mitral commissurotomy (PMC). One hundred and ten patients (pts) were examined by TEE and TTE before PMC. PMC was not performed in eight pts who had a thrombus in the left atrium detected by TEE but not by TTE. Out of the 102 other pts, TEE was better than TTE in detecting mild mitral regurgitation (MR) (84 vs 38, P less than 0.01). Spontaneous contrast was only shown by TEE in 70 pts. On the other hand, planimetry of the valvular area was only possible with TTE. This technique was also better in the assessment of the commissural area. During PMC, TEE enabled the interatrial septum to be punctured in two pts. After PMC, MR was trivial in 49 TEE cases compared with 36 by TTE and was moderate in 20 TEE pts compared with 12 by TTE (P less than 0.02). Transoesophageal colour Doppler showed a trivial atrial shunt in 63% of cases vs 13% by TTE (P less than 0.01).A small atrial septal defect was found in 30 cases only by TEE, and a spontaneous contrast persisted in all pts but six with moderate MR. In conclusion, TEE provides useful information in the ultrasonic assessment of PMC in particular with left atrial thrombi, mitral regurgitation, and the post PMC atrial septal defect. However, both methods are complementary and only TTE enables calculation of valve area.

The purpose of this study was to evaluate various methods of diagnosis of left atrial thrombi (LAT) in patients (pts) with mitral stenosis (MS). From 1980 to 1990, 581 pts with MS have undergone open mitral commissurotomy (n = 169) or valve replacement (n = 412). All pts had transthoracic 2D echocardiography (TTE), 101 transoesophageal echocardiography (TEE), 192 a left atrial angiography (A) (from a left ventricular injection if associated mitral regurgitation grade 3 (n = 154) or from an injection in the pulmonary artery (n = 38) and 229 a coronary angiography (CA). Tomodensitometry (TD), nuclear magnetic resonance (NMR) and 111 Indium platelet imaging (IPI) were performed in some cases, 2, 8 and 5 respectively. All these examinations were carried out in the month before surgery. LAT was found by the surgeon in 43 pts (7%). The site was left atrial appendage in 26 cases (60%) and left atrial cavity in 17 cases. Sensitivity (Se), specificity (Sp) of TTE/TEE/A/CA were the following: TTE, Se% 28, Sp% 99; TEE, Se% 83, Sp% 97; A, Se% 28, Sp% 99; CA, Se% 14, Sp% 100. Specificity was high with all methods but sensitivity was high only with TEE and poor with other methods because of difficulty in detecting thrombi of the left atrial appendage. Specificity and sensitivity of TD, NMR and IPI require more information. False-negative cases are possible with NMR (1 case) and IPI (1 case) in well established LAT. We conclude: TEE is the easiest way to detect LAT, particularly when located in the left atrial appendage. It should be carried out systematically before percutaneous mitral valvuloplasty or surgery.

Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases [Eur Heart Journal (2014) 35, 2873–2926,doi:10.1093/eurheartj/ehu281]. In Table 3, the radiation for MRI is “0” and not “-“. The corrected table is shown below.

Aims: Pulmonary hypertension (PH) is associated with poor prognosis in patients with severe aortic stenosis (AS). The aim of this multicentre study was to describe clinical outcome after transcatheter aortic-valve implantation (TAVI). Methods: The FRANCE 2 registry included all patients undergoing TAVI in France in 2010 and 2011. Patients were divided into 3 groups depending on pre-TAVI systolic pulmonary artery pressure (sPAP) estimated in transthoracic echocardiography: group I, sPAP 60 mmHg (severe PH). Patients were followed up for 1 year. Results: 2,435 patients whose pre-TAVI sPAP was reported were included. 845 were in group I (34.7%), 1,112 in group II (45.7%) and 478 in group III (19.6%). Procedural success, early complications and 30-day mortality were statistically similar across sPAP groups. 1-year mortality was higher in groups II and III (group I, 21.6%; group II, 27.8%; group III, 28.4%; p=0.032). Mild-to-moderate and severe PH was identified as an independent factor of all-cause mortality. The major adverse cardiovascular event rates did not differ according to sPAP. NYHA functional class improved significantly in all groups. View this table: Table 1. Events at 1 year Conclusion: PH (sPAP > 40 mmHg) in AS patients undergoing TAVI was associated with increased 1-year mortality especially when severe (sPAP > 60 mmHg) but not with increased 30-day mortality, and functional status was significantly improved.