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Guzzetti, Ezequiel

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Ezequiel

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  • PublicationAccès libre
    Transvalvular flow, sex, and survival after valve replacement surgery in patients with severe aortic stenosis
    (Elsevier, 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.
  • PublicationRestreint
    Paravalvular regurgitation after transcatheter aortic valve replacement. Is the problem solved?
    (Elsevier, 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.
  • PublicationRestreint
    Measuring progression of aortic stenosis : computed tomography versus echocardiography
    (BMJ Pub. Group, 2020-10-09) Guzzetti, Ezequiel; Clavel, Marie-Annick
  • PublicationAccès libre
    Multimodality imaging in aortic stenosis and its consequences
    (2023) Guzzetti, Ezequiel; Clavel, Marie-Annick; Pibarot, Philippe
    La sténose aortique calcifiante (SA), est également connue sous le nom de SA dégénérative. La SA est la maladie valvulaire cardiaque la plus répandue dans les pays industrialisés. Elle est la conséquence d'un remodelage fibro-calcique progressif survenant sur une valve aortique initialement normale (tricuspide) ou sur une valve aortique congénitalement anormale (bicuspide principalement). La prévalence de la SA augmente généralement avec l'âge, affectant jusqu'à 10 % des personnes de plus de 80 ans. Par conséquent, la SA est considérée comme un problème de santé publique en raison de sa prévalence croissante liée au vieillissement d'une population avec une espérance de vie accrue. La SA est une maladie complexe affectant non seulement la valve mais aussi le myocarde. L'échocardiographie-Doppler reste la pierre angulaire du diagnostic et de la prise en charge de la SA, mais une proportion importante (jusqu'à 35 %) des patients présentent des résultats discordants à l'échocardiographie, ce qui soulève des doutes sur la gravité réelle de la maladie. Des techniques d'imagerie avancées non invasives telles que la tomodensitométrie et la résonance magnétique cardiovasculaire (cardiac magnetic resonance- CMR) se sont progressivement intégrées à l'arsenal diagnostic de la SA. Cependant, de nombreux pièges techniques restent inexplorés et de nombreuses recommandations des guides de pratique sont basées sur des preuves rares ou des hypothèses théoriques. En outre, une grande quantité de preuves est basée sur des populations principalement masculines et caucasiennes, et les différences sexuelles et ethniques restent à élucider. Bien que plusieurs modalités d'imagerie existent, une approche centrée sur le patient doit être encouragée, dans laquelle la technique et l'approche doivent être adaptées aux besoins de chaque patient. L'objectif général de ce projet de thèse est donc d'optimiser l'approche diagnostique des patients atteints de SA par l'imagerie multimodalité. Plus précisément, nous visons à : i) optimiser l'évaluation du débit à l'aide de l'échocardiographie-Doppler et de l'IRM à contraste de phase; ii) améliorer l'évaluation anatomique de la gravité de la SA à l'aide de la tomographie, d'abord en abordant les aspects techniques de la mesure de la calcification de la valve aortique (aortic valve calcification- AVC) et ensuite, en évaluant les différences ethniques; et iii) améliorer l'évaluation de la réponse myocardique à la SA: d'abord en comparant l'évaluation de la masse et dure modelage du ventricule gauche (VG) par échocardiographie en utilisant la CMR comme étalon-or, puis en évaluant la réponse myocardique suite au remplacement de la valve aortique chez des patients atteints de diabète et/ou de syndrome métabolique.
  • PublicationRestreint
    Structural deterioration of transcatheter versus surgical aortic valve bioprostheses in the PARTNER-2 trial
    (Elsevier Biomedical, 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)
  • PublicationAccès libre
    Importance of flow in risk stratification of aortic stenosis.
    (Elsevier, 2020-01-01) Guzzetti, Ezequiel; Pibarot, Philippe; Clavel, Marie-Annick
  • PublicationAccès libre
    Sex-specific correlates of valvular and arterial calcification burden in patients with moderate aortic stenosis
    (BMJ Group, 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.
  • PublicationAccès libre
    Contrast-enhanced computed tomography assessment of aortic stenosis.
    (2021-01-29) Timothy Robert, Graham Cartlidge; Guzzetti, Ezequiel; Bing, Rong; Couture, Christian; Kwiecinski, Jacek; Pibarot, Philippe; Clavel, Marie-Annick; Pawade, Tania; Doris, Mhairi K; Adamson, Philip D; Massera, Daniele; Lembo, Maria; Peeters, Frederique E. C. M.; Berman, Daniel S; Dey, Damini; Slomka, Piotr; Newby, David E; Dweck, Marc R
    Abstract Objectives Non-contrast CT aortic valve calcium scoring ignores the contribution of valvular fibrosis in aortic stenosis. We assessed aortic valve calcific and non-calcific disease using contrast-enhanced CT. Methods This was a post hoc analysis of 164 patients (median age 71 (IQR 66–77) years, 78% male) with aortic stenosis (41 mild, 89 moderate, 34 severe; 7% bicuspid) who underwent echocardiography and contrast-enhanced CT as part of imaging studies. Calcific and non-calcific (fibrosis) valve tissue volumes were quantified and indexed to annulus area, using Hounsfield unit thresholds calibrated against blood pool radiodensity. The fibrocalcific ratio assessed the relative contributions of valve fibrosis and calcification. The fibrocalcific volume (sum of indexed non-calcific and calcific volumes) was compared with aortic valve peak velocity and, in a subgroup, histology and valve weight. Results Contrast-enhanced CT calcium volumes correlated with CT calcium score (r=0.80, p<0.001) and peak aortic jet velocity (r=0.55, p<0.001). The fibrocalcific ratio decreased with increasing aortic stenosis severity (mild: 1.29 (0.98–2.38), moderate: 0.87 (1.48–1.72), severe: 0.47 (0.33–0.78), p<0.001) while the fibrocalcific volume increased (mild: 109 (75–150), moderate: 191 (117–253), severe: 274 (213–344) mm3/cm2). Fibrocalcific volume correlated with ex vivo valve weight (r=0.72, p<0.001). Compared with the Agatston score, fibrocalcific volume demonstrated a better correlation with peak aortic jet velocity (r=0.59 and r=0.67, respectively), particularly in females (r=0.38 and r=0.72, respectively). Conclusions Contrast-enhanced CT assessment of aortic valve calcific and non-calcific volumes correlates with aortic stenosis severity and may be preferable to non-contrast CT when fibrosis is a significant contributor to valve obstruction.
  • PublicationRestreint
    Effect of race on pressure recovery adjustment for prevention of aortic stenosis grading discordance;
    (BMJ Group, 2023-05-05) Oh, Kyung Jin; Shen, Mylène; Guzzetti, Ezequiel; Tastet, Lionel; Loganath, Krithika; Botezatu, Simona; Lee, Seung-Ah; Lee, Sahmin; Kim, Dae-Hee; Song, Jong-Min; Kang, Duk-Hyun; Dweck, Marc R; Pibarot, Philippe; Clavel, Marie-Annick; Song, Jae-Kwan
    Objective We sought to evaluate the potential impact of racial difference (Asians vs Caucasians) on the clinical usefulness of pressure recovery (PR) adjustment for preventing discordant aortic stenosis (AS) grading in patients with severe AS. Methods Data from 1450 patients (mean age, 70.2±10.6 years; 290 (20%) Caucasians; aortic valve area (AVA), 0.77±0.26 cm2) were retrospectively analysed. PR-adjusted AVA was calculated using a validated equation. Discordant grading of severe AS was defined as AVA of <1.0 cm2 and mean gradient of <40 mm Hg. The frequency of discordant grading was assessed in the overall cohort and the propensity scorematched cohort. Results Before PR adjustment, 1186 patients showed AVA values of <1.0 cm2 ; after PR adjustment, 170 (14.3%) were reclassified as having moderate AS. PR adjustment decreased the frequency of discordant grading from 31.4% to 14.1% in Caucasians and from 13.8% to 7.9% in Asians. Patients with reclassification to moderate AS after PR adjustment had a significantly lower risk of a composite of aortic valve replacement or all-cause death than did those with severe AS after PR adjustment (HR 0.38; 95% CI 0.31–0.46; p<0.001). In propensity score-matched cohorts (173 pairs), the frequency of discordant grading before PR adjustment was 42.2% and 43.9% in the Caucasian and Asian patients, respectively, which decreased to 21.4% and 20.2%, respectively, after PR adjustment.Conclusions Clinically relevant PR occurred, regardless of race in patients with moderate to severe AS. Routine PR adjustment may be useful for reconciling discordant AS grading.
  • PublicationAccès libre
    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
    (ScienceDirect, 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