- Email: [email protected]
Aortic-valve calcium score for the diagnosis of severe aortic stenosis: A systematic review and meta-analysis
84 teristics of patients and temporal trends from 2006 to 2016 were described. Results In 2016 5,864 patients were hospitalized for a nRMR, 32% of whom had associated ischemic heart disease and 12% had mitral prolapse, identifiable by the SNDS; 59% were male and the average age was 68 years. A total of 17.9% of these patients had a multivalvular heart disease. The case-fatality rate at 1 year of the index stay was 8.5%. The incidence of patients hospitalized for nRMR increased by 14% between 2006 and 2016, and was 9.1/100,000 PY. Moreover, in 2016, 73% of patients hospitalized for nRMR were operated in the year following the index hospital stay. Conclusion The incidence of patients hospitalized for nRMR increased in recent years. This upward trend is expected to continue with the current development of percutaneous mitral valve procedures. Disclosure of interest The authors declare that they have no competing interest. https://doi.org/10.1016/j.acvdsp.2019.09.177 113
Nationwide incidence of patients hospitalized for a valvular heart disease according to etiology: Patient characteristics and temporal trends in France 2006—2016 C. Grave 1,∗ , C. Tribouilloy 2 , Y. Juillière 3 , P. Tuppin 4 , A. Weill 4 , V. Olié 1 1 Santé publique France, Saint-Maurice 2 Service de Cardiologie, CHU d’Amiens, Amiens 3 Service de Cardiologie, CHU de Nancy, Nancy 4 Direction de la Stratégie des Études et des Statistiques, Caisse nationale de l’Assurance Maladie, Paris, France ∗ Corresponding author. E-mail address: [email protected] (C. Grave) Background The main etiologies of valvular heart disease (VHD) are rheumatic fever and age-related degeneration. In 2016, the prevalence of patients managed for a VHD was 0,6% of the French population (341,500 people). However, few recent incidence data are available in France. Purpose Estimate the annual incidence of patients hospitalized for VHD in France according to their etiology, describe their characteristics and the temporal trends. Methods All patients hospitalized for VHD in France between 2006 and 2016 were identified using data from the national hospital discharge database (PMSI-MCO) integrated into the national health data system (SNDS). The first stay of the year in which the patient was hospitalized with a principal or related diagnosis of VHD was selected. Descriptive analyses of patients’demographic and medical characteristics and trends from 2006—2016 were stratified according to the origin of valvular heart disease. Results In 2016 38,875 patients were hospitalized for a VHD in France. Of these, 89% were hospitalized for non-rheumatic VHD (52.1/100,000 person-year (PY)) with an average age of 74 years; 5% for rheumatic VHD (3.1/100,000 PY) with an average age of 67 years; 3% for congenital VHD (1.1/100,000 PY) with an average age of 29 years; and 3% for unspecified origin. The incidence of patients hospitalized for non-rheumatic VHD increased by 43% between 2006 and 2016, particularly in older patients. It has decreased by 42% for rheumatic VHD. Departmental disparities were observed for these disorders, with a high incidence of hospitalization for rheumatic VHD in the Ile-de-France, the French overseas departments and territories and the south-east. Conclusion The improvement in the management of streptococcal A angina, the increase in life expectancy and the expansion of indications for the management of aortic stenosis and mitral
Valvular heart disease and general cardiology regurgitation by transcatheter valve replacement have reshaped the distribution of types of VHD hospitalized since 2006. Disclosure of interest The authors declare that they have no competing interest. https://doi.org/10.1016/j.acvdsp.2019.09.178 342
Myxomatous degeneration of the bicuspid aortic-valve A. Simoni 1,∗ , A. Theron 1 , E. Faure 2 , A. Touil 1 , F. Collart 1 , S. Zaffran 2 , J.F. Avierinos 3 1 Chirurgie cardiaque adulte, CHU Timone 2 Inserm, Aix Marseille université 3 Service de cardiologie adulte, CHU Timone, Marseille, France ∗ Corresponding author. E-mail address: [email protected] (A. Simoni) Introduction Bicuspid aortic-valve (BAV) is the most common congenital malformation. Complications include aortic stenosis and regurgitation, endocarditis, aortic dilatation and dissection. Although BAV is associated with early valve degeneration, its pathophysiology remains unknown. Purpose The objective of this study was to examine at clinical, histological and molecular levels, a cohort of BAV patients with pure aortic regurgitation (AR-BAV). Methods From 2011 to 2018, patients with BAV were prospectively included. We performed histological and transcriptomic analysis of explanted BAV and compared differences between characteristics of prolapsed leaflet and non-prolapsed leaflet, using a normal tricuspid valve leaflet at reference. Aortic-valves from patients with long term left ventricular assist device (LVAD) were used as a model of acquired aortic regurgitation. Results A total of 350 patients with BAV were included. Among 316 patients (90%) with dysfunctional BAV, 66 (21%) presented severe AR-BAV. Mechanism of AR was prolapse in 37 patients (56%). Histologically, analysis of 2 explanted AR-BAV showed disorganization of extracellular matrix, loss of laminar structure and proteoglycans accumulation on prolapsed leaflet. Inversely, trilaminar structure of the non-prolapsed aortic leaflet was preserved. Transcriptomic analysis revealed upregulation of genes involved in extracellular matrix homeostasis and downregulation of endothelial cell markers on the prolapsed leaflet. The aortic-valve LVAD analysis found histological and molecular results similar to those described in BAV prolapsed leaflet and was associated with occurrence AR. Conclusion AR-BAV is a mood of BAV dysfunction that occurs in young male subjects, as a consequence of myxomatous degeneration similar to that described in mitral valve prolapse. LVAD model suggests that altered hemodynamic environment could account for the acquired nature of valve degeneration. Disclosure of interest The authors declare that they have no competing interest. https://doi.org/10.1016/j.acvdsp.2019.09.179 063
Aortic-valve calcium score for the diagnosis of severe aortic stenosis: A systematic review and meta-analysis T. Vanzwaelmen , J. Magne ∗ , C. Boulogne , E. Martins , V. Aboyans Cardiologie, CHU Limoges, Limoges, France ∗ Corresponding author. E-mail address: [email protected] (J. Magne) Background Aortic stenosis (AS) is the most common valvular disease. Nowadays, the degenerative process including valve calcification is the main etiology. Severe AS is associated with poor prognosis and is an indication for aortic-valve intervention. While echocardiography is the main imaging tool to diagnose and quan-
Valvular heart disease and general cardiology tify AS severity, computed tomography can also be used in difficult cases, and the aortic-valve calcification score is proposed as a proxy to quantify the disease severity. Nevertheless, different thresholds are proposed to grade AS. We performed systematic review and meta-analysis of studies using computed tomography to diagnose severe AS. Method Up to 30/11/2018, the key terms ‘‘aortic-valve’’, ‘‘stenosis’’, ‘‘computed tomography’’, ‘‘calcification’’ or ‘‘calcium’’ were searched in PubMed. Our predefined inclusion criteria were clinical studies to diagnose severe AS by aortic-valve calcification derived from computed tomography. Studies including only native valves and providing cut-off levels for stenosis severity were included. The Agatston method were used and expressed in Agatston unit. Results Eleven from 534 studies, including 4,529 patients, were eligible. Population, AS severity, acquisition modalities and results were heterogenous. Aortic-valve calcification score was accurate to diagnose severe AS (pooled area under the curve = 0.89 ± 0.02). The cut-off levels differed between studies. With meta-analysis, the optimal cut-off was 1,648 AU for general population. Only three studies provided a cut-off per gender, with optimal value derived from meta-analysis of 1,354 AU for women and 2,048 AU for men. Conclusion Aortic-valve calcification score derived from computed tomography is useful to diagnose severe AS. It can provide supplementary data for evaluation of AS in patients with discordant echocardiographic findings. However, individual participant data meta-analysis is required to identify the most appropriate cut-off values with better accuracy. Disclosure of interest The authors declare that they have no competing interest.
85 under medical (P = 0.41), and under medical and surgical management (P = 0.52) (Fig. 1). Conclusions This study shows that NF-LG-SAS have a comparable outcome to that of MAS when AVR was performed during follow-up according to guidelines, mostly at the stage of high-gradient AS. Rigorous echocardiographic assessment to rule out measurement errors and close follow-up are essential in NF-LG-SAS to detect progression to true severe AS.
https://doi.org/10.1016/j.acvdsp.2019.09.180 071
Outcome of normal-flow low-gradient ‘‘severe’’ aortic stenosis with preserved left ventricular ejection fraction: A propensity matched study G. Chadha 1,∗ , Y. Bohbot 1,2 , D. Rusinaru 1,2 , S. Marechaux 2,3 , C. Tribouilloy 1,2 1 Department of Cardiology, Amiens University Hospital 2 EA 7517 MP3CV, Jules Verne University of Picardie, Amiens 3 Groupement des Hôpitaux de l’Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France, Lille, France ∗ Corresponding author. E-mail address: [email protected] (G. Chadha) Background Normal-flow low-gradient severe aortic stenosis (NF-LG-SAS), defined by aortic-valve area < 1cm2 , mean gradient < 40 mmHg and indexed stroke volume > 35 ml/m2 , is the most prevalent form of low-gradient aortic stenosis (AS). However, the true severity of AS and the management of NF-LG-SAS is controversial. The aim of this study was to evaluate the outcome of patients with NF-LG-SAS compared to patients with moderate AS (MAS), who are considered to be suitable for conservative management. Methods and results A total of 520 patients were included in this study: 154 with NF-LG-SAS and 366 with MAS (aortic-valve area between 1.0 and 1.3 cm2 ). On Cox multivariate analysis, after adjustment for covariates of prognostic importance, NF-LG-SAS patients did not exhibit an excess risk of mortality compared to MAS patients, under medical management (P = 0.45) and under medical and surgical management (P = 0.70), even after further adjustment for aortic-valve replacement (AVR) (P = 0.56). The 6-year cumulative incidence of AVR (performed in accordance with current guidelines) was comparable between the two groups (39 ± 4% for NF-LG-SAS and 35 ± 3% for MAS, P = 0.10). After propensity score matching (n = 226), NF-LG-SAS patients and MAS patients also had comparable outcomes
Fig. 1 Kaplan—Meier curves of survival according to aortic stenosis form under medical and surgical management in the propensity matched cohort (n = 226). Disclosure of interest peting interest.
The authors declare that they have no com-
https://doi.org/10.1016/j.acvdsp.2019.09.181 050
CT is the main component of the global exposure to ionizing radiation for patients benefiting from a trans-femoral TAVR A. Villecourt 1,∗ , L. Faroux 1 , T. Blanpin 1,2 , M. Kinnel 1 , C. Mora 3 , S. Tassan-Mangina 1 , V. Heroguelle 1 , P. Nazeyrollas 1 , D. Metz 1 1 Department of Cardiology 2 Department of Radiation Protection 3 Department of Radiology, Reims University Hospital, Reims, France ∗ Corresponding author. E-mail address: [email protected] (A. Villecourt) Background X-rays are widely used for the TAVR realization, for the pre-TAVR assessment (coronary angiography ± PCI and computed tomography), and sometimes in the aftermath of the intervention (electrophysiology study, pacemaker implantation). TAVR currently becomes an alternative to surgical valve replacement for patients at intermediate risk, a population that is likely to experience an increase of the radiation-induced cancer risk following TAVR. Purpose The main objective of our study was therefore to evaluate the overall exposure to ionizing radiation for patients benefiting from a trans-femoral TAVR. Methods All patients who underwent trans-femoral TAVR for a symptomatic aortic stenosis in our centre over a 26 months period were included. Dosimetric indicators (i.e. dose area product or dose length product) of pre-procedural coronary angiography and computed tomography, TAVR procedure, and any post-procedural
Nationwide incidence of patients hospitalized for a valvular heart disease according to etiology: Patient characteristics and temporal trends in France 2006—2016 C. Grave 1,∗ , C. Tribouilloy 2 , Y. Juillière 3 , P. Tuppin 4 , A. Weill 4 , V. Olié 1 1 Santé publique France, Saint-Maurice 2 Service de Cardiologie, CHU d’Amiens, Amiens 3 Service de Cardiologie, CHU de Nancy, Nancy 4 Direction de la Stratégie des Études et des Statistiques, Caisse nationale de l’Assurance Maladie, Paris, France ∗ Corresponding author. E-mail address: [email protected] (C. Grave) Background The main etiologies of valvular heart disease (VHD) are rheumatic fever and age-related degeneration. In 2016, the prevalence of patients managed for a VHD was 0,6% of the French population (341,500 people). However, few recent incidence data are available in France. Purpose Estimate the annual incidence of patients hospitalized for VHD in France according to their etiology, describe their characteristics and the temporal trends. Methods All patients hospitalized for VHD in France between 2006 and 2016 were identified using data from the national hospital discharge database (PMSI-MCO) integrated into the national health data system (SNDS). The first stay of the year in which the patient was hospitalized with a principal or related diagnosis of VHD was selected. Descriptive analyses of patients’demographic and medical characteristics and trends from 2006—2016 were stratified according to the origin of valvular heart disease. Results In 2016 38,875 patients were hospitalized for a VHD in France. Of these, 89% were hospitalized for non-rheumatic VHD (52.1/100,000 person-year (PY)) with an average age of 74 years; 5% for rheumatic VHD (3.1/100,000 PY) with an average age of 67 years; 3% for congenital VHD (1.1/100,000 PY) with an average age of 29 years; and 3% for unspecified origin. The incidence of patients hospitalized for non-rheumatic VHD increased by 43% between 2006 and 2016, particularly in older patients. It has decreased by 42% for rheumatic VHD. Departmental disparities were observed for these disorders, with a high incidence of hospitalization for rheumatic VHD in the Ile-de-France, the French overseas departments and territories and the south-east. Conclusion The improvement in the management of streptococcal A angina, the increase in life expectancy and the expansion of indications for the management of aortic stenosis and mitral
Valvular heart disease and general cardiology regurgitation by transcatheter valve replacement have reshaped the distribution of types of VHD hospitalized since 2006. Disclosure of interest The authors declare that they have no competing interest. https://doi.org/10.1016/j.acvdsp.2019.09.178 342
Myxomatous degeneration of the bicuspid aortic-valve A. Simoni 1,∗ , A. Theron 1 , E. Faure 2 , A. Touil 1 , F. Collart 1 , S. Zaffran 2 , J.F. Avierinos 3 1 Chirurgie cardiaque adulte, CHU Timone 2 Inserm, Aix Marseille université 3 Service de cardiologie adulte, CHU Timone, Marseille, France ∗ Corresponding author. E-mail address: [email protected] (A. Simoni) Introduction Bicuspid aortic-valve (BAV) is the most common congenital malformation. Complications include aortic stenosis and regurgitation, endocarditis, aortic dilatation and dissection. Although BAV is associated with early valve degeneration, its pathophysiology remains unknown. Purpose The objective of this study was to examine at clinical, histological and molecular levels, a cohort of BAV patients with pure aortic regurgitation (AR-BAV). Methods From 2011 to 2018, patients with BAV were prospectively included. We performed histological and transcriptomic analysis of explanted BAV and compared differences between characteristics of prolapsed leaflet and non-prolapsed leaflet, using a normal tricuspid valve leaflet at reference. Aortic-valves from patients with long term left ventricular assist device (LVAD) were used as a model of acquired aortic regurgitation. Results A total of 350 patients with BAV were included. Among 316 patients (90%) with dysfunctional BAV, 66 (21%) presented severe AR-BAV. Mechanism of AR was prolapse in 37 patients (56%). Histologically, analysis of 2 explanted AR-BAV showed disorganization of extracellular matrix, loss of laminar structure and proteoglycans accumulation on prolapsed leaflet. Inversely, trilaminar structure of the non-prolapsed aortic leaflet was preserved. Transcriptomic analysis revealed upregulation of genes involved in extracellular matrix homeostasis and downregulation of endothelial cell markers on the prolapsed leaflet. The aortic-valve LVAD analysis found histological and molecular results similar to those described in BAV prolapsed leaflet and was associated with occurrence AR. Conclusion AR-BAV is a mood of BAV dysfunction that occurs in young male subjects, as a consequence of myxomatous degeneration similar to that described in mitral valve prolapse. LVAD model suggests that altered hemodynamic environment could account for the acquired nature of valve degeneration. Disclosure of interest The authors declare that they have no competing interest. https://doi.org/10.1016/j.acvdsp.2019.09.179 063
Aortic-valve calcium score for the diagnosis of severe aortic stenosis: A systematic review and meta-analysis T. Vanzwaelmen , J. Magne ∗ , C. Boulogne , E. Martins , V. Aboyans Cardiologie, CHU Limoges, Limoges, France ∗ Corresponding author. E-mail address: [email protected] (J. Magne) Background Aortic stenosis (AS) is the most common valvular disease. Nowadays, the degenerative process including valve calcification is the main etiology. Severe AS is associated with poor prognosis and is an indication for aortic-valve intervention. While echocardiography is the main imaging tool to diagnose and quan-
Valvular heart disease and general cardiology tify AS severity, computed tomography can also be used in difficult cases, and the aortic-valve calcification score is proposed as a proxy to quantify the disease severity. Nevertheless, different thresholds are proposed to grade AS. We performed systematic review and meta-analysis of studies using computed tomography to diagnose severe AS. Method Up to 30/11/2018, the key terms ‘‘aortic-valve’’, ‘‘stenosis’’, ‘‘computed tomography’’, ‘‘calcification’’ or ‘‘calcium’’ were searched in PubMed. Our predefined inclusion criteria were clinical studies to diagnose severe AS by aortic-valve calcification derived from computed tomography. Studies including only native valves and providing cut-off levels for stenosis severity were included. The Agatston method were used and expressed in Agatston unit. Results Eleven from 534 studies, including 4,529 patients, were eligible. Population, AS severity, acquisition modalities and results were heterogenous. Aortic-valve calcification score was accurate to diagnose severe AS (pooled area under the curve = 0.89 ± 0.02). The cut-off levels differed between studies. With meta-analysis, the optimal cut-off was 1,648 AU for general population. Only three studies provided a cut-off per gender, with optimal value derived from meta-analysis of 1,354 AU for women and 2,048 AU for men. Conclusion Aortic-valve calcification score derived from computed tomography is useful to diagnose severe AS. It can provide supplementary data for evaluation of AS in patients with discordant echocardiographic findings. However, individual participant data meta-analysis is required to identify the most appropriate cut-off values with better accuracy. Disclosure of interest The authors declare that they have no competing interest.
85 under medical (P = 0.41), and under medical and surgical management (P = 0.52) (Fig. 1). Conclusions This study shows that NF-LG-SAS have a comparable outcome to that of MAS when AVR was performed during follow-up according to guidelines, mostly at the stage of high-gradient AS. Rigorous echocardiographic assessment to rule out measurement errors and close follow-up are essential in NF-LG-SAS to detect progression to true severe AS.
https://doi.org/10.1016/j.acvdsp.2019.09.180 071
Outcome of normal-flow low-gradient ‘‘severe’’ aortic stenosis with preserved left ventricular ejection fraction: A propensity matched study G. Chadha 1,∗ , Y. Bohbot 1,2 , D. Rusinaru 1,2 , S. Marechaux 2,3 , C. Tribouilloy 1,2 1 Department of Cardiology, Amiens University Hospital 2 EA 7517 MP3CV, Jules Verne University of Picardie, Amiens 3 Groupement des Hôpitaux de l’Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France, Lille, France ∗ Corresponding author. E-mail address: [email protected] (G. Chadha) Background Normal-flow low-gradient severe aortic stenosis (NF-LG-SAS), defined by aortic-valve area < 1cm2 , mean gradient < 40 mmHg and indexed stroke volume > 35 ml/m2 , is the most prevalent form of low-gradient aortic stenosis (AS). However, the true severity of AS and the management of NF-LG-SAS is controversial. The aim of this study was to evaluate the outcome of patients with NF-LG-SAS compared to patients with moderate AS (MAS), who are considered to be suitable for conservative management. Methods and results A total of 520 patients were included in this study: 154 with NF-LG-SAS and 366 with MAS (aortic-valve area between 1.0 and 1.3 cm2 ). On Cox multivariate analysis, after adjustment for covariates of prognostic importance, NF-LG-SAS patients did not exhibit an excess risk of mortality compared to MAS patients, under medical management (P = 0.45) and under medical and surgical management (P = 0.70), even after further adjustment for aortic-valve replacement (AVR) (P = 0.56). The 6-year cumulative incidence of AVR (performed in accordance with current guidelines) was comparable between the two groups (39 ± 4% for NF-LG-SAS and 35 ± 3% for MAS, P = 0.10). After propensity score matching (n = 226), NF-LG-SAS patients and MAS patients also had comparable outcomes
Fig. 1 Kaplan—Meier curves of survival according to aortic stenosis form under medical and surgical management in the propensity matched cohort (n = 226). Disclosure of interest peting interest.
The authors declare that they have no com-
https://doi.org/10.1016/j.acvdsp.2019.09.181 050
CT is the main component of the global exposure to ionizing radiation for patients benefiting from a trans-femoral TAVR A. Villecourt 1,∗ , L. Faroux 1 , T. Blanpin 1,2 , M. Kinnel 1 , C. Mora 3 , S. Tassan-Mangina 1 , V. Heroguelle 1 , P. Nazeyrollas 1 , D. Metz 1 1 Department of Cardiology 2 Department of Radiation Protection 3 Department of Radiology, Reims University Hospital, Reims, France ∗ Corresponding author. E-mail address: [email protected] (A. Villecourt) Background X-rays are widely used for the TAVR realization, for the pre-TAVR assessment (coronary angiography ± PCI and computed tomography), and sometimes in the aftermath of the intervention (electrophysiology study, pacemaker implantation). TAVR currently becomes an alternative to surgical valve replacement for patients at intermediate risk, a population that is likely to experience an increase of the radiation-induced cancer risk following TAVR. Purpose The main objective of our study was therefore to evaluate the overall exposure to ionizing radiation for patients benefiting from a trans-femoral TAVR. Methods All patients who underwent trans-femoral TAVR for a symptomatic aortic stenosis in our centre over a 26 months period were included. Dosimetric indicators (i.e. dose area product or dose length product) of pre-procedural coronary angiography and computed tomography, TAVR procedure, and any post-procedural