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Cardiac troponin (cTn) concentrations are measured routinely in some centers after cardiac surgery as part of risk stratification, but there are no data on how increased cTn concentrations could change patients' management. The aim of this study was to estimate relevant cTnI thresholds and identify potential interventions (additional monitoring/therapeutic interventions) that could be part of management changes of patients with cTnI greater than relevant thresholds.Retrospective, single-center, observational study.Bichat-Claude Bernard Hospital, Paris, France, between January 1, 2009, and December 31, 2012.Consecutive adult patients undergoing cardiac surgery.cTnI was measured on the 20th postoperative hour. Causes of death and possible interventions were determined by analysis of individual medical records. cTnI thresholds for 1-year cardiac mortality with a specificity80% were calculated. For this study, 3,228 procedures were analyzed; 129 deaths occurred (4%), 83 of which (2.6%) were cardiac deaths. Threshold cTnI values were 4.2 µg/L for coronary artery bypass grafting (95% confidence interval [CI] 3.9-4.5) and 10.7 µg/L for non-coronary artery bypass grafting (95% CI 10.0-11.3). In multivariable analysis, the EuroSCORE II (odds ratio 1.1 [95% CI 1.06-1.13]; p0.001) and cTnI concentrations greater than the thresholds (odds ratio 5.62 [95% CI 3.37-9.37]; p0.001) were associated with significantly increased risk of death. The additive and absolute Net Reclassification Index were 0.288% and 14.1%, respectively, for a logistic model including cTnI and EuroSCORE II (area under the curve C-index 0.82 [95% CI 0.77-0.87]) compared with a model including only EuroSCORE II (area under the curve C-index 0.80 [95% CI 0.75-0.84]). Fifty-three of the 83 patients who experienced cardiac death (64%) had a cTnI concentration greater than the threshold, and an intervention was deemed possible in 47 of those 53 (89%) (mostly patients with mild postoperative cardiac dysfunction). For noncardiac deaths, 28% of patients had a cTnI concentration greater than the threshold and no interventions were deemed possible.In an attempt to evolve from risk to management stratification, this study's results identified a subgroup of patients with mild cardiac dysfunction and a cTnI concentration greater than the threshold who could be the target for interventions in future validation studies concerning changes in patient management.

Bicuspid aortic valve affects 1–2% of babies at birth and is frequently associated with thoracic aortic aneurysm but the risk of aortic dissection is low. Indications for aortic surgery are based on studies on natural history. Aortic surgery is recommended when the maximum aortic diameter is greater than 55 mm in patients with a bicuspid aortic valve. Intervention is indicated at an earlier stage when there are associated risk factors, in particular familial history of aortic dissection or rapid progression, or if there is an indication for aortic valve replacement. The choice between partial or total replacement of the aorta should be based on anatomy, but also take into account the patient’s age and operative risk.

International audience; Aortic stenosis is a frequent disease in the elderly. Its prevalence is 0.4% with a sharp increase after the age of 65, and its outcome is very poor when the patient becomes symptomatic. The interventional procedure known as TAVI (trans-catheter aortic valve implantation), which was developed in France and carried out for the first time in Rouen by Prof. Alain Cribier and his team in 2002, has proven to be a valid alternative to surgical aortic valve replacement. At first, this technique was shown to be efficient in patients with contra-indications to surgical treatment or deemed to be at high surgical risk. Given the very promising outcomes achieved as a result of close heart team collaboration, appropriate patient selection, simplified procedures and reduced complication rates, transfemoral (TF) TAVI is now preferred in symptomatic intermediate risk patients>75 years old according to the latest ESC guidelines. In 2017, in France, TAVI is currently performed in 50 centers with on-site cardiac surgery. The 2016 TAVI outcomes recorded in the French national TAVI registry (France TAVI) are very encouraging and show that for 7133 patients treated (age 83.4±7 years, logistic Euroscore 14%), 87% of whom via the TF approach, cross-over to surgery was very low (0.5%) with a 3.0% in-hospital mortality rate. The substantial increase in TAVI indications and the improvement of its outcomes may in the near future call for a reconsideration of the number of high volume centers authorized to carry out this technique.

Aortic diseases encountered in young women are mainly associated with syndromic diseases, which are often heritable, or bicuspid aortic valve. The most frequent syndromic disease is Marfan syndrome. In Marfan syndrome, the risk of aortic dissection is low during pregnancy when the maximum diameter of the ascending aorta is less than 45 mm. Dissection may affect the thoracic ascending or descending aorta. The risk of aortic dissection is low in bicuspid aortic valve when the aortic diameter is less than 50 mm. Beta blockers are recommended throughout pregnancy in Marfan syndrome and are often used in other causes of aortic aneurysms. Close echocardiographic follow-up is needed during pregnancy and after delivery.

The incidence of infective endocarditis (IE) is estimated at between 15 and 60 cases per million inhabitants per year from population-based studies in industrialized countries. The presentation of IE has changed since patients are getting older and Staphylococcus is now becoming the microorganism most frequently responsible, which is partly attributable to healthcare-associated infections. The incidence of IE is higher in patients with heart valve prosthesis, previous endocarditis, and complex congenital heart disease. In developing countries, IE occurs in younger patients with a majority of rheumatic valve disease and is most frequently due to streptococci. IE is the consequence of bacteraemia on a diseased native valve or foreign material, leading to vegetation or tissue destruction, or both of these. The main consequences of these lesions are heart failure due to valvular regurgitation, embolic events due to vegetation migration, and perivalvular abscesses.

In patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR), the impact of concomitant mitral stenosis (MS) remains unknown. The aim of this study was to determine the incidence and impact of moderate to severe MS in patients undergoing TAVR.The study included 2113 consecutive patients (mean age: 80 ± 9 years, mean STS: 6.4 ± 5.2%) who underwent TAVR in 2 centers. The presence of MS was defined as a mean transmitral gradient ≥ 5 mm Hg on baseline echocardiography in the absence of severe mitral regurgitation. Clinical events were prospectively collected in a dedicated TAVR database.A total of 157 patients (7.4%) had moderate to severe MS (mean gradient: 7.2 ± 2.8 mm Hg; degenerative origin in 88%). Patients with MS were younger, more frequently women, had a higher left ventricular ejection fraction and an increased rate of severe pulmonary hypertension (p 0.02 for all). Thirty-day mortality was similar in both groups (MS: 3.8%; no MS: 5.5%, adjusted p = 0.34). At a mean follow-up of 3 ± 2 years, there were no differences between groups in mortality (MS: 35%, no MS: 36.2%, adjusted HR: 1.14, 95% CI: 0.86-1.51), or heart failure rehospitalization (MS: 21%, no MS: 21.7%; adjusted HR: 1.16, 95% CI: 0.81-1.67). Patients with MS exhibited a similar functional status at follow-up compared to those with no MS (NYHA I-II in 85% and 88% of patients, respectively, adjusted p = 0.20).About 7% of patients undergoing TAVR had concomitant moderate to severe MS. The presence of MS had no negative impact on early and mid-term clinical outcomes post-TAVR. These results suggest that TAVR is a valid alternative for treating patients with aortic stenosis in the presence of moderate to severe MS.

Summary Background Cardiovascular disease (CVD) is a major cause of death worldwide, and fruitful research is needed for future advances in this field. Aims To analyse the scientific production and vitality of French cardiovascular clinical research, and its evolution over the last decade. Methods We first used Lab Times online data obtained through the Web of Science (Thomson-Reuters, Toronto, ON, Canada), then the PubMed database (National Center for Biotechnology Information [NCBI], Bethesda, MD, USA), for studies published between 2005 and 2015 in the multidisciplinary and cardiology journals with the highest impact factors. French abstracts submitted and accepted at the European Society of Cardiology (ESC) congress were provided directly by the ESC. The number of cardiovascular projects was analysed through the http://www.ClinicalTrials.gov database and the French site for government-funded projects, over the decade from 2008 to 2017. Results Overall, France was ranked fifth in Europe and eighth worldwide for CVD publications. During the 10-year period from 2005 to 2015, French publications accounted for 0.2–0.3% of articles in top multidisciplinary journals and 2% of articles in top cardiology journals. We observed a steady decrease in French abstract submissions at the ESC congress (from 5% to 3.5% in 10 years), and in 2017, France was ranked eighth in Europe. Across European countries, France has been ranked first for declared cardiovascular research on http://www.ClinicalTrials.gov over the last 3 years, for both interventional and observational studies. Regarding the Hospital Programme of Clinical Research, heart ranked second after neurosciences. Conclusions France is very well represented in terms of new CVD projects, but actual French scientific production scores poorly. Investing in CVD research is a priority to increase the level of publication and to compete with other leading countries.

Objectives We sought to assess the impact of mitral annular calcification (MAC) and associated mitral stenosis (MAC-MS) on clinical outcomes of transcatheter aortic valve replacement (TAVR). Background MAC is a common finding in patients undergoing TAVR. Studies evaluating the impact of MAC on the outcomes of TAVR have yielded conflicting results. Furthermore, the impact of MAC-MS remains unknown. Methods We evaluated all the patients who consecutively underwent TAVR in our institution between January 2008 and May 2018. The presence of MAC was confirmed on computed tomography (CT). The combination of MAC and a mean transmitral gradient ≥ 5 mmHg defined MAC-MS. Results The study included 1177 patients, of whom 504 (42.8%) had. Patients with MAC had similar outcomes after TAVR than those without except for a higher rate of permanent pacemaker implantation which more frequently occurred in MAC patients (adjusted HR: 1.32, 95%CI: 1.03–1.69, P = 0.03). Similar findings were observed when only patients with severe MAC were selected. Among MAC patients, 85 (7.2%) had MAC-MS. Compared to no–MAC patients, MAC-MS was an independent predictor of all-cause mortality at 30 days (adjusted HR: 2.30,95%CI: 1.08–4.86, P = 0.03) and 1–year (adjusted HR: 1.73, 95%CI: 1.04–2.89, P = 0.04). Conclusions MAC is a common finding in patients treated with TAVR and even severe does not impact on most clinical outcomes. However, when associated with MS, it is an independent predictor of all-cause mortality and cardiovascular mortality at 1 year. In patients with MAC, the measurement of the transmitral gradient is simple, reproducible and effective to identify those at high early and late risk after TAVR.

Hyperemia is a major criterion for the diagnosis of acute myocarditis on cardiac magnetic resonance imaging but its assessment is challenging and time consuming. We evaluated the usefulness of the contrast-enhanced first-pass perfusion (FPP) on magnetic resonance imaging for detecting subepicardial hyperemia in acute myocarditis. Forty-seven consecutive patients (mean age: 42 ± 15.6 years; 35 men) with a definite diagnosis of acute myocarditis according to the state-of-the-art guidelines were included and compared with 16 control subjects. FPP was evaluated by 2 blinded observers and compared with the reference late gadolinium enhancement. Detection of hyperemia was performed on both qualitative and quantitative methods. Relative increased signal intensity (SI) in the subepicardial hyperemic layer was measured with SI ratio (SI of the subepicardial layer/SI of the immediately adjacent subendocardial layer). Twenty-four patients (51%) with acute myocarditis exhibited subepicardial hyperemia, detected with a good interobserver reproducibility (kappa coefficient: 0.75). The SI in the myocardium of myocarditis patients was increased compared with controls (1.08 ± 0.03 vs 0.945 ± 0.04, p = 0.03) and the SI in myocarditis patients with hyperemia compared with those without hyperemia (1.22 ± 0.04 vs 0.94 ± 0.04, p

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.

AIMS Our aim was to assess one-year outcomes of patients enrolled in the pilot European Sentinel Registry of Transcatheter Aortic Valve Implantation (TAVI). METHODS AND RESULTS One-year outcomes of 4,571 patients (81.4±7.2 years, 2,291 [50.1%] male) receiving TAVI with the SAPIEN XT (57.3%) or CoreValve prosthesis at 137 European centres were analysed using Kaplan-Meier and Cox proportional hazards regression techniques. At one year, 3,341 patients were alive, 821 had died, and 409 were lost to follow-up. Of 2,125 patients who underwent functional assessment, 1,916 (90%) were in New York Heart Association (NYHA) Class I/II at one year, with functional improvement from baseline noted in 1,682 patients (88%). One-year survival based on 4,564 patients was estimated at 79.1%. Independent baseline predictors of mortality were increasing age and logistic EuroSCORE, the presence of NYHA III/IV, chronic obstructive pulmonary disease, and atrial fibrillation. Female gender was associated with a 4% survival benefit at one year. Vascular access routes other than transfemoral were associated with poorer survival. Procedural failure and major periprocedural complications had an adverse impact on survival. CONCLUSIONS Contemporary European experience attests to the effectiveness of routine TAVI in unselected elderly patients.

Surgery for aortic stenosis in patients with thoracic radiation therapy is associated with high morbi-mortality. Trans-catheter aortic valve implantation (TAVI) represents an alternative but has never been studied in this population. We aimed to compare outcomes in radiation and matched control patients undergoing TAVI and to identify predictive factors of survival.Between 2006 and 2011, 288 consecutive patients underwent TAVI in our institution, of whom 26 had previous chest radiation. They were matched 1:1 for age, sex and TAVI approach with controls.In both groups, median age was 73 years, 50% of patients were male and 15% had a transapical approach. Procedural success was 88% in the radiation group versus 100% in controls (p0.001) and 30-day survival was 92% in both groups. Five-year survival was 33%±10% in the radiation group and 42%±11% in controls (p=0.26). In radiation patients, the main cause of death was respiratory insufficiency in 40%. We identified four independent predictive factors of death in the radiation group: extracardiac arteriopathy (p=0.002) and the absence of β-blocker therapy (p=0.005) as preprocedural variables, and infectious complications (p=0.009) and a higher peak creatinine level (p=0.009) as postprocedural variables. In the radiation group, 89% of survivors were in New York Heart Association class I-II at last follow-up.Patients in the radiation group displayed high mortality rates although not significantly different from the controls. Respiratory failure was the main cause of death, emphasising the need for a careful pulmonary evaluation. Finally, we show a sustained improvement in functional results after TAVI in this population.

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.

Learning objectives In this review, we will discuss the current knowledge of heart valve disease (HVD) epidemiology, how it has changed over time and possible future trends. There are large differences in HVD epidemiology between high-income and low-income countries and across different forms of HVD. The majority of morbidity and mortality attributable to HVD worldwide is due to rheumatic heart disease (RHD), which is most commonly seen in low-income countries. In high-income countries, the greatest burden of HVD referred to hospital is due to calcific aortic valve disease (CAVD). Although prevalence of HVD is low compared with coronary heart disease, the requirement for long-term follow-up, and significant investigation and treatment costs, means that the impact of HVD on healthcare systems is disproportionately large. The strong association between HVD and age, combined with the rapid ageing of populations worldwide, means that HVD has been described as the ‘next cardiac epidemic’.1 ### Current knowledge Acute rheumatic fever (ARF) occurs a number of weeks after Streptococcus pyogenes (group A streptococcus) infection, usually in children. ARF leads to valve inflammation through molecular mimicry between the streptococcal M protein and cardiac proteins such as myosin and vimentin, although it is likely that other mechanisms are also involved.2 The requirements for ARF to lead to chronic RHD are not yet fully established but are likely to be related to repeated episodes of often subclinical secondary infection, leading to progressive valve fibrosis and self-sustaining valve inflammation. Those with repeated infections are more likely to progress to chronic RHD, and extended antibiotic prophylaxis is recommended for those with a …

The spectrum of valvular heart diseases (VHDs) has evolved during the past decades in the developed countries. However, there are few epidemiological data on VHD and large contemporary population-based studies are lacking. In this issue of the journal, Andell et al present the findings of a nationwide study in Sweden that includes a population of about 10 million people.1 The authors used nationwide registers to identify all patients with first diagnosis of VHD at Swedish hospitals between 2003 and 2010. The cases diagnosed in the years 2000, 2001 and 2002 were excluded, therefore allowing to estimate the incidence rates of VHDs. The incidence of each VHD was then stratified for age and sex. Andell et al should be commended for this elegant and important study that provides a contemporary and comprehensive portrait of the epidemiology spectrum of VHD within a large European country.1 Previous epidemiology studies on VHD included either representative samples2 or primary care series recruited locally3 and the majority of these studies reported only prevalence rates. Incidence rates have been previously reported for aortic stenosis (AS)4 5 but the present study is the first to report incidence rates for the different VHDs. Over the 8-year period of the present study conducted in the Swedish population, a new diagnosis of VHD was identified in close to 77 000 persons.1 The overall incidence of VHD was 63.9 per 100 000 person-years and the most common disease was AS (47%) , followed by mitral regurgitation (MR) (24%) and aortic regurgitation (AR) (18%) (figure 1). In the vast majority (68.9%) of the cases, the VHDs were diagnosed in subjects aged ≥65 years, except for pulmonary valve disease whose incidence peaked in newborns. Half of the persons with AS also had atherosclerotic vascular disease, which provides further support to the commonality …

Background Transcatheter mitral valve implantation (TMVI) is emerging as an alternative to surgical mitral valve replacement (SMVR) in selected high-risk patients. It may avoid redo-biological SMVR and delay definitive mechanical SMVR in young women wishing for pregnancy and suffering from failure of mitral bioprosthesis or annuloplasty. Purpose To evaluate the feasibility, safety and outcomes of TMVI in this specific population. Methods From 2013 to 2018, 12 young women with degenerated mitral bioprostheses (n = 6) and annuloplasties (n = 6), pregnant (n = 1) or wishing for pregnancy (n = 11), were treated with transseptal valve-in-valve or valve-in-ring TMVI, using the Edwards SAPIEN XT/3 valves, and were prospectively followed at 1 month, 6 months, 1 year and yearly thereafter. Results Mean age was 29 ± 5 years and EuroSCORE II 3.2 ± 0.8%. The mode of failure was stenosis in 9 cases and regurgitation in 3. Systolic pulmonary artery pressure was 56 ± 26 mmHg. One TMVI was performed in emergency, in the setting of severe bioprosthesis failure complicated by cardiogenic shock and multiorgan failure. One per-procedure prosthesis atrial embolization occurred and required a conversion to standard surgery. One intra-ventricular obstruction was secondarily observed and lead to an elective SMVR. Median follow-up was 36 (4–51) months. At 6 months/1 year, 83% of the patients were in NYHA classes I/II. Mitral regurgitation was ≤ 1+ in all the cases and mean gradient was 8 ± 2 mmHg. Three patients could achieve 4 uneventful pregnancies. At last follow-up, there was no death and 3 patients underwent definitive mechanical SMVR. Conclusion Valve-in-valve and valve-in-ring TMVIs avoid redo biological SMVR and allow young women carrying through uneventful pregnancies. This strategy delays definitive mechanical SMVR and the drawbacks of anticoagulation and may appear as a promising option in young women contemplating pregnancy.

Background The chronic use of systemic corticosteroid (CS) therapy is associated with greater tissue fragility. Data assessing the effects of this treatment on the results of transcatheter aortic-valve implantation (TAVI) are scarce. Purpose To describe the impact of chronic use of CS treatment on early and late outcomes after TAVI. Methods and Results All 1299 consecutive patients undergoing TAVI in our institution between October 2006 and November 2018 were included. Their mean age was 81 ± 10 years, 52.4% were male, their median EuroSCORE 2 was 4.7% (2.8–7.5). Among them, 48 (3.7%) received chronic systemic CS treatment at the time of the procedure and were compared to those without CS. Patients with chronic CS therapy tended to be women (60% vs. 47%, P = 0.078) and needed more frequently dialysis (12.5% vs. 2.6%, P = 0.002). All other baseline clinical and echocardiographic characteristics were similar between both groups. No differences were observed in 30-day mortality (6.2% vs. 4.3%, P = 0.46). However, after adjustment, patients in the CS group had more frequent major vascular complications (16.7% vs. 7.4%, hazard ratio (HR) 2.52, 95%Confidence Interval (CI) 1.14–5.9; P = 0.02), major or life-threatening bleedings (22.9% vs. 12.4%, HR 2.02, 95%CI 1.00–4.08; P = 0.05) and tamponades (8.3% vs. 2.4%, HR 4.05, 95%CI 1.35–12.15, P Fig. 1 ). Conclusion Chronic systemic CS treatment was associated with an increase in major or life-threatening bleedings, major vascular complications and tamponades at 30 days and was an independent predictor of 1-year all-cause mortality. This treatment should be taken into account in the risk stratification of TAVI candidates.

The optimal antithrombotic treatment after transcatheter aortic valve replacement (TAVR) remains a matter of debate. Although dual antiplatelet therapy is recommended, single antiplatelet therapy or oral anticoagulation is frequently used according to the patient profile. Whether this approach may affect clinical outcome is unknown.FRANCE TAVI (French Transcatheter Aortic Valve Implantation) is a prospective, multicenter, nationwide French registry. The study objectives were to identify independent correlates of long-term all-cause mortality and early bioprosthetic valve dysfunction (BVD), defined as increased prosthetic gradient ≥10 mm Hg or new gradient ≥20 mm Hg.To account for missing values, multiple imputations were performed. Stepwise multivariable Cox regression and logistic regression were used for all-cause mortality and bioprosthesis valve dysfunction was used, respectively. Sensitivity analysis retaining only patients with complete data were also performed.Of 12,804 patients included in the registry between January 1, 2013, and December 31, 2015, a total of 11,469 (mean ± SE age: 82.8 ± 0.07 years; logistic European System for Cardiac Operative Risk Evaluation: 17.8 ± 0.1%; mean duration of follow-up: 495 ± 3.5 days) were alive at discharge with known antithrombotic treatment and were analyzed for mortality. A total of 2,555 patients had at least 2 echocardiographic evaluations and were eligible for BVD assessment. One-third of patients had a history of atrial fibrillation, and the same proportion had oral anticoagulation at discharge (n = 3,836). Neither aspirin nor clopidogrel was independently associated with mortality. Male sex (adjusted hazard ratio [aHR]: 1.63; 95% confidence interval [CI]: 1.44 to 1.84; p 0.001), history of atrial fibrillation (aHR: 1.41; 95% CI: 1.23 to 1.62; p 0.001), and chronic renal failure (aHR: 1.37; 95% CI: 1.23 to 1.53; p 0.001) were the strongest independent correlates of mortality. Anticoagulation at discharge (adjusted odds ratio [aOR]: 0.54; 95% CI: 0.35 to 0.82; p = 0.005) and a nonfemoral approach (aOR: 0.53; 95% CI: 0.28 to 1.02; p = 0.049) were independently associated with lower rates of BVD, whereas chronic renal failure (aOR: 1.46; 95% CI: 1.03 to 2.08; p = 0.034) and prosthesis size ≤23 mm (aOR: 3.43; 95% CI: 2.41 to 4.89; p 0.001) yielded higher risk of BVD.Sex, renal failure, and atrial fibrillation affected mortality the most at the 3-year follow-up. In contrast, anticoagulation (mostly given for atrial fibrillation) decreased the risk of BVD after TAVR.

Prosthetic valve replacement is the most frequent valvular surgery. The choice between a mechanical prosthesis and a bioprosthesis should not overstress the role of age, and should take into account in particular the wishes of the informed patient. Patients with a mechanical prosthesis require lifelong treatment using VKA with a target INR adapted to the prosthesis and patient characteristics, while non-vitamin K antagonist oral anticoagulants are contra-indicated. The association of low-dose aspirin is restricted to selected patients with a mechanical prosthesis who have atherosclerosis or recurrent embolism. The post-operative period is at risk of thromboembolism and bleeding and requires increased awareness on the monitoring of anticoagulant therapy. The management of anticoagulant therapy during non-cardiac surgery should be adapted to the type of surgery. Minor procedures generally do not require interruption of anticoagulation. Dual antiplatelet therapy is recommended after transcatheter aortic valve implantation but ongoing trials will probably refine antithrombotic regimen.

Valvular heart disease is a frequent underlying heart disease in pregnant women. Mitral stenosis is often rheumatic in origin, while aortic stenosis is more often congenital. Stenotic lesions carry a high risk of complications. Mitral stenosis with a valve area less than 1.5 cm2 should be considered for pre-pregnancy intervention, especially when balloon valvulotomy is an option, since the risk of maternal and fetal complications is high. For women with aortic stenosis, pre-pregnancy intervention should be considered when the woman is symptomatic, or when left ventricular function or exercise testing is abnormal. Regurgitant lesions carry a lower risk than stenotic lesions. Women with a mechanical prosthesis have a high risk of complications during pregnancy and should be managed in a centre of expertise. Vitamin K antagonists are associated with embryopathy, but only in the first trimester and mainly when higher dosages are needed. Vitamin K antagonists are superior to prevent valve thrombosis. Vitamin K antagonists are advised in the first trimester when the daily dose requirement is low, and are preferred in the second and third trimester. During the first trimester, alternative options are unfractionated or low-molecular-weight heparins with intensive monitoring of anticoagulation effect. Heparins are also used from the 36th week of pregnancy until delivery. Most women with valvular disease can deliver vaginally.

Physiologic haemodynamic changes during pregnancy carry a risk of cardiac complications in women with valvular disease. Mitral stenosis with valve area

The risk of cardiovascular complications in patients undergoing non-cardiac surgery depends risk on the type of non-cardiac surgery, classified into 3 groups, and the type and severity of valvular disease. The risk of complications is highest in aortic stenosis In symptomatic patients, aortic stenosis should be treated before non-cardiac surgery, while asymptomatic patients with severe aortic stenosis can undergo elective non-cardiac surgery. In symptomatic patients with mitral stenosis, percutaneous mitral commissurotomy should be attempted before high-risk non-cardiac surgery. In asymptomatic patients with severe regurgitation and preserved left ventricular systolic function, non-cardiac surgery can be performed safely. In patients with mechanical prosthesis, the main problem is the adaptation of the modalites of anticoagulant therapy.

Valvular heart disease (VHD) is frequent is industrialized countries and its prevalence increases with age due to the predominance of degenerative aetiology. Clinical approach is paramount for evaluation of the patient’s history, symptoms and for the detection of VHD by auscultation. Echocardiography plays a major role in diagnosis and assessment of severity and prognosis. Other investigations are mainly non-invasive and include stress testing, multimodality imaging and biomarkers. Risk stratification is essential to weigh the risk of intervention against the expected natural history of VHD. It should include risk scores, keeping in mind their limitations, in particular in the elderly. Heart valve centres are required to deliver high-quality care and provide adequate training. Non-vitamin K antagonist oral anticoagulants may be used in patients with atrial fibrillation and aortic stenosis, aortic regurgitation, mitral regurgitation, or aortic bioprostheses beyond 3 months after implantation, but are contraindicated in mitral stenosis and mechanical valves.

The evaluation of the risk of non-cardiac surgery in patients with valvular disease should take into account the type, severity, and tolerance of valvular disease, and the risk inherent to non-cardiac surgery. Aortic stenosis carries the highest risk of perioperative complications. Except for emergency non-cardiac surgery, an intervention on the aortic valve is indicated firstly in case of severe symptomatic aortic stenosis. In asymptomatic patients, low- and intermediate-risk non-cardiac surgery can be performed, while the strategy should be individualized for high-risk non-cardiac surgery. Balloon aortic valvuloplasty may be used as a bridge if non-cardiac surgery is urgent. Percutaneous mitral commissurotomy should be considered in symptomatic patients with severe mitral stenosis. In patients with severe aortic or mitral regurgitation, the risk of non-cardiac surgery is low if they are asymptomatic with preserved left ventricular ejection fraction. In patients with a mechanical prosthesis, perioperative anticoagulant therapy should be adapted to the haemorrhagic risk of intervention and to the patient- and prosthesis-related thromboembolic risk.

This study sought to compare outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) in a catheterization laboratory (cath lab) to those undergoing TAVR in a hybrid operating room (OR).TAVR can be performed in a cath lab or in a hybrid OR. Comparisons between these locations are scarce.All TAVRs performed in 48 centers across France between January 2013 and December 2015 were prospectively included in the FRANCE TAVI (French Transcatheter Aortic Valve Implantation) registry. The primary endpoint of this study was all-cause mortality at 1 year. Secondary endpoints consisted of 30-day complications and 3-year mortality. All analyses were adjusted for baseline and procedural characteristics.A total of 12,121 patients were included in this study, 62% of which underwent TAVR in a cath lab versus 38% in a hybrid OR. Mean age was 82.9 ± 7.2 years, 48.9% of patients were men, and mean Logistic EuroScore was 17.9% ± 12.3%. Both procedure locations showed similar, below 2% rates of intraprocedural complications. After adjusting for baseline and procedural characteristics, major bleeding and infections were significantly higher in the hybrid OR group (bleeding, 6.3% vs. 4.8%; infection, 6.1% vs. 3.5%; p 0.05). Adjusted mortality rates at 1 and 3 years did not differ significantly between groups (for cath lab vs. hybrid OR, respectively: 1 year: 16.2% vs. 15.8%; p = 0.91; 3 years: 38.4% vs. 36.4%; p = 0.49).Midterm mortality after TAVR was similar between the cath lab and the hybrid OR. These findings support the performance of TAVR in either location, which has important implications on health care organization and costs.

This study sought to describe the current practices and compare outcomes according to the use of balloon aortic valvuloplasty (BAV) or not during transcatheter aortic valve replacement (TAVR).Since its development, aortic valve pre-dilatation has been an essential step of TAVR procedures. However, the feasibility of TAVR without systematic BAV has been described.TAVR performed in 48 centers across France between January 2013 and December 2015 were prospectively included in the FRANCE TAVI (Registry of Aortic Valve Bioprostheses Established by Catheter) registry. We compared outcomes according to BAV during the TAVR procedure.A total of 5,784 patients have been included in our analysis, corresponding to 2,579 (44.6%) with BAV avoidance and 3,205 (55.4%) patients with BAV performed. We observed a progressive decline in the use of BAV over time (78% of procedures in 2013 and 49% in the last trimester of 2015). Avoidance of BAV was associated with similar device implantation success (97.3% vs. 97.6%; p = 0.40). TAVR procedures without BAV were quicker (fluoroscopy 17.2 ± 9.1 vs. 18.5 ± 8.8 min; p 0.01) and used lower amounts of contrast (131.5 ± 61.6 vs. 141.6 ± 61.5; p 0.01) and radiation (608.9 ± 576.3 vs. 667.0 ± 631.3; p 0.01). The rates of moderate to severe aortic regurgitation were lower with avoidance of BAV (8.3% vs. 12.2%; p 0.01) and tamponade rates (1.5% vs. 2.3%; p = 0.04).We confirmed that TAVR without BAV is frequently performed in France with good procedural results. This procedure is associated with procedural simplification and lower rates of residual aortic regurgitation.

Transcatheter heart valve interventions have transformed the outcomes of patients with valvular heart disease (VHD) who are unfavourable candidates for surgery. Technological advances have allowed extension of these interventions to younger or lower risk patients and those with other forms of VHD and may in the future permit earlier treatment of VHD in less symptomatic patients or those with moderate disease. The balance of risks and benefits is likely to differ between lower and higher risk patients, and more evidence is needed to evaluate the net benefit of transcatheter technology in these groups. As academic researchers, clinicians, industry, and patient stakeholders collaborate to research these broader indications for transcatheter valve interventions, it is essential to address (i) device durability and deliverability, (ii) specific anatomical needs (e.g. bicuspid aortic valves, aortic regurgitation, mitral and tricuspid valve disease), (iii) operator training, and (iv) the reinforced importance of the multidisciplinary Heart Team.

El texto completo y el documento complementario de casos clinicos de la presente actualizacion se encuentran disponibles en: www.escardio.org/Guidelines/Clinical-Practice-Guidelines/2017-focused-update-on-dual-antiplatelet-therapy-dapt .

Background: The FRANCE-2 registry (French Aortic National Corevalve and Edwards) previously reported good early- and medium-term clinical and echocardiographic efficacy for transcatheter aortic valve replacement. We here report 5-year follow-up results from the registry. Methods: The registry includes all consecutive patients undergoing transcatheter aortic valve replacement for severe aortic stenosis in France. Follow-up is scheduled at 30 days, 6 months, then annually from 1 to 5 years. Clinical events were defined according to the Valve Academic Research Consortium criteria, and hemodynamic structural valve deterioration (SVD) was defined according to the consensus statement by the European Association of Percutaneous Cardiovascular Interventions. Results: Between January 2010 and January 2012, 4201 patients were enrolled in 34 centers. Five-year vital status was available for 95.5% of patients; 88.1% had clinical evaluation or died. Overall, at 5 years, all-cause mortality was 60.8% (n=2478; 95% CI, 59.3% to 62.3%). The majority of cardiovascular events occurred in the first month after valve implantation, and incidence remained low thereafter, at P =0.1). Finally, in the population of patients with severe SVD, 1 patient (1.7%) experienced a stroke, and 8 patients presented ≥1 heart failure event (13.3%). Conclusions: The 5-year follow-up results of the FRANCE-2 registry represent the largest long-term data set available in a high-risk population. In surviving patients, the low rate of clinical events and the low level of SVD after 1 year support the long-term efficacy of transcatheter aortic valve replacement in both types of transcatheter prosthesis featuring in the registry.

Aims To assess the knowledge and application of European Society of Cardiology (ESC) Guidelines in the management of mitral regurgitation (MR). Methods and results A mixed-methods educational needs assessment was performed. Following a qualitative phase (interviews), an online survey was undertaken using three case scenarios (asymptomatic severe primary MR, symptomatic severe primary MR in the elderly, and severe secondary MR) in 115 primary care physicians (PCPs), and 439 cardiologists or cardiac surgeons from seven European countries. Systematic cardiac auscultation was performed by only 54% of clinicians in asymptomatic patients. Cardiologists appropriately interpreted echocardiographic assessment of mechanism and quantification of primary MR (≥75%), but only 44% recognized secondary MR as severe. In asymptomatic severe primary MR with an indication for surgery, 27% of PCPs did not refer the patient to a cardiologist and medical therapy was overused by 19% of cardiologists. In the elderly patient with severe symptomatic primary MR, 72% of cardiologists considered mitral intervention (transcatheter edge-to-edge valve repair in 72%). In severe symptomatic secondary MR, optimization of medical therapy was advised by only 51% of PCPs and 33% of cardiologists, and surgery considered in 30% of cases (transcatheter edge-to-edge repair in 64%). Conclusion Systematic auscultation is underused by PCPs for the early detection of MR. Medical therapy is overused in primary MR and underused in secondary MR. Indications for interventions are appropriate in most patients with primary MR, but are unexpectedly frequent for secondary MR. These gaps identify important targets for future educational programs.

Questions and Answers on Diagnosis and Management of Patients with Peripheral Arterial Diseases : A Companion Document of the 2017 ESC Guidelines for the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS).

We read with great interest the paper by Lindman et al. [(1)][1] published in iJACC . The investigators thoroughly scrutinized the current approach to asymptomatic patients with severe aortic stenosis (AS) and the validity of symptom-driven timing to valve replacement in older populations often

Introduction Transcatheter aortic valve implantation (TAVI) is playing a growing role in the management of patients with symptomatic severe aortic stenosis. However, length of hospital stay (LOS) after transfemoral (TF) TAVI remains widely variable. Objective We aimed to evaluate LOS after TF TAVI and the variability of LOS among French centers using data from the FRANCE TAVI registry. Methods TAVI was performed in 12,804 patients in 48 French centers between January 2013 and December 2015. LOS was evaluated in 5,857 (45.7%) patients treated via a TF approach and discharged directly at home. LOS was calculated from TAVI procedure (day 0) to discharge. The study population was divided into 2 groups based on tertile LOS values. Results The median LOS in the studied population was 7 (5–9) days and was extremely variable among centers. Patients in the lowest tertile (LOS 6 days (n = 3,624) constituted the “Late Discharge group”. Variables independently associated with late discharge were comorbidities (history of mitral valve prosthesis, respiratory failure, atrial fibrillation, and severe pulmonary hypertension), complications occurring during or after TAVI (need for a new pacemaker, tamponade, stroke, vascular complications and acute kidney injury), the use of self-expandable valve and general anesthesia with a significant center effect. In contrast, the history of previous pacemaker before TAVI was a protective factor. Finally, we did not observe any significant difference in the rate of death and re-admission in the early versus late discharge groups. Conclusion LOS remain high after TF TAVI in France and extremely variable. As expected, co-morbidities and complications were predictive factors of late discharge after TAVI. Furthermore, our results suggest that the use of self-expandable prosthesis and general anesthesia also contributes to late discharge.

Background In the context of extension of transcatheter aortic valve implantation (TAVI) indications to lower-risk patients, long-term durability of transcatheter aortic bioprosthetic valves (TABV) is a crucial issue. There is a paucity of data, especially beyond 5 years of follow-up. Recently, new definitions have been proposed to assess structural valve deterioration (SVD) and bioprosthetic valve failure (BVF). Purpose We aim to assess long-term SVD and BVF of TABV using standardized new definitions. Methods All TAVI patients implanted between 2002 and 2011 in 5 French centers were included. One month and last available echocardiographic follow-up were used to assess SVD and BVF of according to the new European criteria. Competing-risk analysis was used to assess SVD and BVF incidence. Results From 2002 to 2011, 1403 patients were included. Mean age and logistic EuroSCORE were 82.6 ± 7.5 years and 21.3 ± 7.5%. Mean duration follow-up was 3.6 ± 2.1 years with a maximum of 10.2 years. Survival rates were 83.5% (95% CI: 81.4–85.5), 18.6% (95% CI: 15.3–21.8) and 8.0% (95% CI: 1.9–14.2) at 1, 7 and 10 years, respectively. BVF occurred in 18 patients of whom 5 required reoperation with a mean delay of 5.5 ± 1.3 years. Incidence of BVF was 2.2% (95% CI: 1.2–3.7) and 3.4 (95% CI: 1.7–5.9) at 7 and 10 years, respectively. Among 589 patients eligible for the SVD analysis, 41 had moderate SVD and 15 had severe SVD. Incidence of moderate SVD was 9.2% (95% CI: 6.5–12.6) and 16.6% (95% CI: 9.1–26.0) at 7 and 10 years, respectively. Incidence of severe SVD was 4.4% (95% CI: 2.2–7.9) and 8.0% (95% CI: 3.3–15.2) at 7 and 10 years, respectively. Conclusions Despite the low survival rates of the early treated TAVI population in France, we believe reporting the longest follow-up available. Our study does not highlight any alarm signal concerning late durability of TABV. Further studies are warranted to assess long-term durability of TABV particularly in younger and lower risk-patients.

Efforts to develop and refine percutaneous approaches to cardiac valve repair and replacement have advanced rapidly over the past several years, having exceeded even the most optimistic expectations. New innovations have been predominantly directed toward the most frequent form of valvular heart disease (VHD) in the industrialized world; aortic stenosis (AS). Approximately 250,000 transcatheter aortic valve implantation (TAVI) procedures have been done so far addressing this significant medical need. Because of the predominance of degenerative etiologies, the prevalence of VHD increases markedly in population above the age of 65 years, in particular with regard to severe AS. As the populations of the industrialized countries continue to be older, the need for less invasive and safer methods of treating severe AS will continue to grow. In this review we provide comprehensive and up-to-date overview of TAVI in current clinical practice. We have also addressed dilemmas and unanswered questions related to TAVI procedures in different groups of patients and highlighted opportunities and trends related to future TAVI implementation.

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to surgical aortic valve replacement (SAVR), but unbiased data regarding evolution of the treatment of patients with aortic stenosis at the nationwide level are scarce.This study sought to evaluate the number of aortic valve replacements (AVRs) performed in France, changes over time, and the effect of the adoption of TAVR.Based on a French administrative hospital-discharge database, the study collected all consecutive AVRs performed in France between 2007 and 2015.A total of 131,251 interventions were performed: 109,317 (83%) SAVR and 21,934 (17%) TAVR. AVR linearly increased (from 10,892 to 18,704; p for trend 0.0001) mainly due to a marked increase in TAVR (from 244 to 6,722; p for trend = 0.0004), whereas SAVR remained stable (from 10,892 to 11,982; p for trend = 0.18). Parallel to a decrease in the Charlson index (p for trend 0.05), SAVR and TAVR in-hospital mortality rates significantly declined (both p for trend 0.01). The number of TAVRs significantly increased in all age categories (75, 75 to 79, 80 to 84, and ≥85 years of age; all p for trend = 0.003), but reached or even exceeded SAVR in the 2 oldest categories. Although mortality rates declined for both isolated SAVR and TAVR, it became similar or slightly lower for TAVR than for isolated SAVR in 2015 in the 3 oldest age categories even if it did not reach statistical significance (p = 0.66, p = 0.47, and p = 0.06, respectively).The number of AVRs markedly increased in France between 2007 and 2015 due to the wide adoption of TAVR, which represented one-third of all AVRs in 2015. Patients' profile improved, suggesting that patients are referred earlier, and in-hospital mortality declined in all AVR subsets. Despite a worse clinical profile, the immediate outcome of TAVR compared favorably to isolated SAVR in patients75 years of age. The results may have major implications for clinical practice and policymakers.