Personne : Guzzetti, Ezequiel
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Transvalvular flow, sex, and survival after valve replacement surgery in patients with severe aortic stenosis
2020-04-28, Bilodeau, Anthony, Guzzetti, Ezequiel, Kalavrouziotis, Dimitri, Zhang, Bin, Couture, Christian, Annabi, Mohamed Salah, Pibarot, Philippe, Clavel, Marie-Annick, Dagenais, François
Background : The respective impacts of transvalvular flow, gradient, sex, and their interactions on mortality in patients with severe aortic stenosis undergoing surgical aortic valve replacement (AVR) are unknown. Objectives : This study sought to compare the impact of pre-operative flow-gradient patterns on mortality after AVR and to examine whether there are sex differences. Methods : This study analyzed clinical, echocardiographic, and outcome data prospectively collected in 1,490 patients (544 women [37%]), with severe aortic stenosis and preserved left ventricular ejection fraction who underwent AVR. Results : In this cohort, 601 patients (40%) had normal flow (NF) with high gradient (HG), 405 (27%) NF with low gradient (LG), 246 (17%) paradoxical low flow (LF)/HG, and 238 (16%) LF/LG. During a median follow-up of 2.42 years (interquartile range: 1.04 to 4.29 years), 167 patients died. Patients with LF/HG exhibited the highest mortality after AVR (hazard ratio [HR]: 2.01; 95% confidence interval [CI]: 1.33 to 3.03; p < 0.01), which remained significant after multivariate adjustment (HR: 1.96; 95% CI: 1.29 to 2.98; p < 0.01). Both LF/LG and NF/LG patients had comparable outcome to NF/HG (p ≥ 0.47). Optimal thresholds of stroke volume index were obtained for men (40 ml/m2) and women (32 ml/m2). Using these sex-specific cutpoints, paradoxical LF was independently associated with increased mortality in both women (adjusted HR: 2.05; 95% CI: 1.21 to 3.47; p < 0.01) and men (adjusted HR: 1.54; 95% CI: 1.02 to 2.32; p = 0.042), whereas guidelines’ threshold (35 ml/m2) does not. Conclusions : Paradoxical LF/HG was associated with higher mortality following AVR, suggesting that a reduced flow is a marker of disease severity even in patients with HG aortic stenosis. Early surgical AVR (i.e., before gradient attains 40 mm Hg) might be preferable in these patients. Furthermore, the use of sex-specific thresholds (<40 ml/m2 for men and <32 ml/m2 for women) to define low-flow outperforms the guidelines’ threshold of 35 ml/m2 in risk stratification after AVR.
Importance of flow in risk stratification of aortic stenosis.
2020-01-01, Guzzetti, Ezequiel, Pibarot, Philippe, Clavel, Marie-Annick
Pre- and post-operative stroke volume impact after surgical aortic valve replacement for severe aortic stenosis
2020-10-19, Guzzetti, Ezequiel, Poulin, Anthony, Kalavrouziotis, Dimitri, Annabi, Mohamed Salah, Pibarot, Philippe, Clavel, Marie-Annick, Dagenais, François
Multimodality imaging for discordant low-gradient aortic stenosis : assessing the valve and the myocardium
2020-12-03, Guzzetti, Ezequiel, Annabi, Mohamed Salah, Pibarot, Philippe, Clavel, Marie-Annick
Aortic stenosis (AS) is a disease of the valve and the myocardium. A correct assessment of the valve disease severity is key to define the need for aortic valve replacement (AVR), but a better understanding of the myocardial consequences of the increased afterload is paramount to optimize the timing of the intervention. Transthoracic echocardiography remains the cornerstone of AS assessment, as it is universally available, and it allows a comprehensive structural and hemodynamic evaluation of both the aortic valve and the rest of the heart. However, it may not be sufficient as a significant proportion of patients with severe AS presents with discordant grading (i.e., an AVA ≤1 cm2 and a mean gradient
Paravalvular regurgitation after transcatheter aortic valve replacement. Is the problem solved?
2018-10-01, Dahou, Abdellaziz, Guzzetti, Ezequiel, Annabi, Mohamed Salah, Pibarot, Philippe, Clavel, Marie-Annick, Toubal, Oumhani, Ong, Géraldine, Salaun, Erwan
Paravalvular regurgitation is a frequent complication after transcatheter aortic valve replacement and its association with worse outcomes depends on the degree of its severity. Despite substantial improvement in transcatheter heart valve design, sizing and implantation technique, moderate or severe paravalvular regurgitation still occurs in 2% to 7% of patients and is associated with a more than 2-fold increase in mortality. This review provides a state-of-the-art approach to (i) paravalvular regurgitation prevention by optimizing patient selection, valve sizing, and positioning and (ii) the detection, quantitation and management of paravalvular regurgitation during and after valve implantation.
Sex-specific correlates of valvular and arterial calcification burden in patients with moderate aortic stenosis
2022-12-01, Deslandes, Marianne, Paquin, Amélie, Guzzetti, Ezequiel, Beaudoin, Jonathan, Barriault, Alexandra, Salaun, Erwan, Clavel, Marie-Annick
Introduction: There are significant sex differences in the prevalence and severity of cardiac calcifying processes. Women harbour more severe mitral annular calcification (MAC), while men exhibit worse aortic valve (AVC) and coronary artery (CAC) calcification. To better understand these differences, we investigated the correlates of cardiac calcification according to sex. Methods: We conducted a cross-sectional study of 406 patients with ≥mild aortic stenosis (AS) defined by an aortic valve area ≤1.5 cm2 , a peak aortic jet velocity >2.0 m/s, or a mean transvalvular gradient >15 mm Hg. Doppler-echocardiography and non-contrast multidetector CT were performed concomitantly to assess AS and cardiac calcifications. Results: Mean age was 71±11 years and 33% were women. The AS haemodynamics were not significantly different between sexes (all p>0.50), with a mean indexed aortic valve area of 0.59±0.21 cm2 /m2 , peak aortic jet velocity of 2.78 (2.37–3.68) m/s, and mean gradient of 17.9 (12.8–31.3) mm Hg for the whole cohort. Compared with men, women harboured lower AVC (480 (222–1191) vs 1003 (484–2329) Agatston unit, AU; p<0.0001) and CAC (366 (50–914) vs 618 (167–1357) AU; p=0.007), but more severe MAC (60 (1–887) vs 48 (0–351) AU; p=0.08) and ascending aorta calcification (227 (43–863) vs 142 (7–493) AU; p=0.03). After comprehensive adjustment, sex remained an independent predictor of each cardiac calcification subtype (all p<0.02) except for the ascending aorta (p=0.32). In multivariable analysis, certain variables, like age or bicuspid aortic valve, were associated with the calcification scores in both sexes. Sexspecific predictors of calcification burden were absence of angiotensin receptor blockers (β=−0.26; p=0.007) and renal impairment (β=0.26; p=0.003) for AVC, and bisphosphonates (β=0.20; p=0.05) for CAC in women; coronary artery disease (β=0.25; p=0.001) for AVC, and angiotensin receptor blockers (β=0.19; p=0.02) and calcium/vitamin D (β=0.15; p=0.02) for MAC in men. Conclusion: In AS, factors associated with cardiac valvular and arterial calcification differ between sexes, suggesting an important contributory role of sex in the pathophysiology of these calcifying processes.
Effect of regional upper septal hypertrophy on echocardiographic assessment of left ventricular mass and remodeling in aortic stenosis
2020-10-14, Guzzetti, Ezequiel, Garcia, Julio, Larose, Éric, Shen, Mylène, Le Ven, Florent, Bédard, Élisabeth, Capoulade, Romain, Annabi, Mohamed Salah, Pibarot, Philippe, Clavel, Marie-Annick, Tastet, Lionel, Arsenault, Marie
Background: Transthoracic echocardiography (TTE) is the reference method for evaluation of aortic stenosis (AS), and it is extensively used to quantitate left ventricular (LV) mass and volumes. Regional upper septal hypertrophy (USH) or septal bulge is a frequent finding in patients with AS and may lead to overestimation of LV mass when using linear measurements. The objective of this study was to compare estimates of LV mass obtained by two-dimensional transthoracic echocardiographic LV dimensions measured at different levels of the LV cavity with those obtained by cardiovascular magnetic resonance (CMR). Methods: One hundred six patients (mean age, 63 ± 15 years; 68% men) with AS were included in this subanalysis of the PROGRESSA study. Two-dimensional transthoracic echocardiographic measurements of LV dimensions were obtained at the basal level (BL; as recommended in guidelines), immediately below the septal bulge (BSB), and at a midventricular level (ML). Regional USH was defined as a basal interventricular septal thickness ≥ 13 mm and >1.3 times the thickness of the septal wall at the ML. Agreement between transthoracic echocardiographic and CMR measures was evaluated using Bland-Altman analysis. Results: The distribution of AS severity was mild in 23%, moderate in 57%, and severe in 20% of patients. Regional USH was present in 28 patients (26%). In the whole cohort, two-dimensional TTE overestimated LV mass (bias: BL, +60 ± 31 g; BSB, +59 ± 32 g; ML, +54 ± 32 g; P = .02). The biplane Simpson method slightly but significantly underestimated LV end-diastolic volume (bias -10 ± 20 mL, P < .001) compared with CMR. Overestimation of LV mass was more marked in patients with USH when measuring at the BL and was significantly lower when measuring LV dimensions at the ML (P < .025 vs BL and BSB). Conclusions: Two-dimensional TTE systematically overestimated LV mass and underestimated LV volumes compared with CMR. However, the bias between TTE and CMR was less important when measuring at the ML. Measurements at the BL as suggested in guidelines should be avoided, and measurements at the ML should be preferred in patients with AS, especially in those with USH.
Structural deterioration of transcatheter versus surgical aortic valve bioprostheses in the PARTNER-2 trial
2020-10-12, Dahou, Abdellaziz, Guzzetti, Ezequiel, Beaudoin, Jonathan, Annabi, Mohamed Salah, Bernier, Mathieu, Pibarot, Philippe, Clavel, Marie-Annick, Salaun, Erwan, Ternacle, Julien
BACKGROUND It is unknown whether transcatheter valves will have similar durability as surgical bioprosthetic valves. Definitions of structural valve deterioration (SVD), based on valve related reintervention or death, underestimate the incidence of SVD. OBJECTIVES This study sought to determine and compare the 5-year incidence of SVD, using new standardized definitions based on echocardiographic follow-up of valve function, in intermediate-risk patients with severe aortic stenosis given transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) in the PARTNER (Placement of Aortic Transcatheter Valves) 2A trial and registry. METHODS In the PARTNER 2A trial, patients were randomly assigned to receive either TAVR with the SAPIEN XT or SAVR, whereas in the SAPIEN 3 registry, patients were assigned to TAVR with the SAPIEN 3. The primary endpoint was the incidence of SVD, that is, the composite of SVD-related hemodynamic valve deterioration during echocardiographic follow-up and/or SVD-related bioprosthetic valve failure (BVF) at 5 years. RESULTS Compared with SAVR, the SAPIEN-XT TAVR cohort had a significantly higher 5-year exposure adjusted incidence rates (per 100 patient-years) of SVD (1.61 ± 0.24% vs. 0.63 ± 0.16%), SVD-related BVF (0.58 ± 0.14% vs. 0.12 ± 0.07%), and all-cause (structural or nonstructural) BVF (0.81 ± 0.16% vs. 0.27 ± 0.10%) (p ≤ 0.01 for all). The 5-year rates of SVD (0.68 ± 0.18% vs. 0.60 ± 0.17%; p ¼ 0.71), SVD-related BVF (0.29 ± 0.12% vs. 0.14 ± 0.08%; p ¼ 0.25), and all-cause BVF (0.60 ± 0.15% vs. 0.32 ± 0.11%; p ¼ 0.32) in SAPIEN 3 TAVR were not significantly different to a propensity score matched SAVR cohort. The 5-year rates of SVD and SVD-related BVF were significantly lower in SAPIEN 3 versus SAPIEN XT TAVR matched cohorts. CONCLUSIONS Compared with SAVR, the second-generation SAPIEN XT balloon-expandable valve has a higher 5-year rate of SVD, whereas the third-generation SAPIEN 3 has a rate of SVD that was not different from SAVR. (The PARTNER II Trial: Placement of AoRTic TraNscathetER Valves - PII A [PARTNERII A]; NCT01314313; The PARTNER II Trial: Placement of AoRTic TraNscathetER Valves II - PARTNER II - PARTNERII - S3 Intermediate [PARTNERII S3i]; NCT03222128)
Impact of metabolic syndrome and/or diabetes mellitus on left ventricular mass and remodeling in patients with aortic stenosis before and after aortic valve replacement
2019-01-01, Guzzetti, Ezequiel, Shen, Mylène, Voisine, Pierre, Annabi, Mohamed Salah, Poirier, Paul, Piché, Marie-Eve, Zenses, Anne-Sophie, Pibarot, Philippe, Clavel, Marie-Annick, Ong, Géraldine, Dagenais, François, Tastet, Lionel, Salaun, Erwan
Background: In aortic stenosis (AS), metabolic syndrome (MetS) and diabetes mellitus (DM) are associated with more pronounced left ventricular hypertrophy (LVH) and more concentric remodeling. We aimed to assess the impact of MetS and DM on left ventricular (LV) mass, remodeling and LV mass regression after aortic valve replacement (AVR) in patients with severe AS. Method: We included 177 patients with severe AS and preserved LVEF (>50%). All patients had comprehensive echocardiography before and one year after AVR. Results: Twenty-seven percent (27%) of patients had MetS, 21% DM and 52% neither MetS nor DM (No MetS-DM). Prior to AVR, indexed LV mass (LVMi) was higher in MetS and DM groups compared to NoMetS-DM group (56.1±14.2, 56.2±18.2 vs. 49.2±14.1 g/m2.7 respectively; p<0.01). Prevalence of LV hypertrophy was higher in MetS and DM than in NoMetS-DM patients (66%, 65% vs 44%, p<0.01) as well as LV mass to-end-diastolic volume ratio (2.10±0.44 and 2.21±0.63 vs 1.96±0.41 g/ml respectively, p=0.03). One year after AVR, decrease in LVMi was significant (p<0.001) in all 3 groups. DM and MetS were independently associated with higher baseline LVMi (p<0.05). MetS was independently associated with less LVM regression and higher LVMi 1 year after AVR. MetS and DM groups showed more residual LV hypertrophy than NoMetS-DM patients (57%, 38% and 17%, p<0.01). Conclusions: MetS and DM were independently associated with a higher preoperative LVMi and more concentric remodeling. One year after AVR, MetS was associated with less LVMi regression and higher LVMi. MetS and DM patients remained with more residual LV hypertrophy
Multiplanar "En Face" reconstruction of the aortic valve : impact on aortic valve calcium
2020-07-29, Clisson, Marine, Guzzetti, Ezequiel, Clavel, Marie-Annick, Simard, Louis