Personne : Lemieux, Jérôme
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Images in cardiovascular medicine: transapical aortic valve implantation in a patient with severe aortic stenosis and Pott disease
2009-10-20, Bertrand, Olivier, Lemieux, Jérôme, Dumont, Éric, De Larochellière, Robert, Gingras, Luc, Rodés-Cabau, Josep, Bergeron, Sébastien, Bagur, Rodrigo Hernan, Doyle, Daniel, Pibarot, Philippe
Electrocardiographic changes and clinical outcomes after transapical aortic valve implantation
2009-08-01, Gutiérrez-Marcos, José, Bertrand, Olivier, Lemieux, Jérôme, Dumont, Éric, De Larochellière, Robert, Côté, Mélanie, Villeneuve, Jacques, Rodés-Cabau, Josep, Bergeron, Sébastien, Bagur, Rodrigo Hernan, Doyle, Daniel, Poirier, Paul, Pibarot, Philippe, Clavel, Marie-Annick
Background : Transapical aortic valve implantation (TAVI) for the treatment of severe aortic stenosis requires the insertion of a large catheter through the left ventricular apex. However, the electrocardiographic (ECG) changes associated with the incision and repair of the left ventricular apex and the potential damage to the conduction system caused by implanting a balloon-expandable valve in aortic position are not known. The objective of our study was to determine the incidence, type, and timing of ECG changes associated with TAVI. Methods : The standard 12-lead ECGs of 33 consecutive patients (mean age 81 ± 9 years, 13 men) diagnosed with symptomatic severe aortic stenosis (valve area 0.62 ± 0.16 cm2) who underwent TAVI with an Edwards-SAPIEN valve were analyzed at baseline (within 24 hours before the procedure), immediately (within 6 hours) after the procedure, at hospital discharge, and at 1-month follow-up. Results : There were no procedural deaths, and 30-day mortality was 6%. The incidence of complete left ventricular branch block (LBBB) and left anterior hemiblock (LAHB) increased from 9% and 3% at baseline to 27% and 36% after the procedure, respectively (P < .03 for both). A lower (ventricular) position of the valve relative to the hinge point of the anterior mitral leaflet was associated with a higher incidence of new LBBB (35% vs 0%, P = .029); and a greater valve size–aortic annulus ratio, with the occurrence of new LAHB (1.20 ± 0.07 vs 1.14 ± 0.06, P = .021). At 1-month follow-up, the rate of LBBB and LAHB decreased to 13% and 10%, respectively (P = not significant compared with baseline). There were no cases of new atrioventricular block, and no patient needed pacemaker implantation. Transient (<48 hours) ST-elevation changes, mostly in the anterior and/or lateral leads, occurred in 6 patients (18%) immediately after the procedure; but only 1 of these patients presented new Q waves at 1-month follow-up. Conclusions : Transapical aortic valve implantation was associated with a significant but transient (<1 month) increase in LBBB and LAHB, with no patient requiring pacemaker implantation. These changes were partially related to both lower (more ventricular) valve positioning and greater valve oversizing. Transient (<48 hours) ST-segment elevation changes occurred in about one fifth of the patients after the procedure, but only a minority developed new Q waves in the ECG.
Usefulness of TEE as the primary imaging technique to guide transcatheter transapical aortic valve implantation
2011-02-01, Bertrand, Olivier, Lemieux, Jérôme, Dumont, Éric, De Larochellière, Robert, Côté, Mélanie, Villeneuve, Jacques, Rodés-Cabau, Josep, Bergeron, Sébastien, Bagur, Rodrigo Hernan, Doyle, Daniel, Pibarot, Philippe
Objectives: The aim of this study was to: 1) determine the usefulness of transesophageal echocardiography (TEE) as the primary technique to guide transapical (TA) transcatheter aortic valve implantation (TAVI); and 2) to compare TEE with angiography as the primary imaging modality for TA-TAVI guidance. Background: TEE has been routinely used as an adjunct to angiography during TA-TAVI procedures, but very few data exist on the use of TEE as the primary imaging technique guiding TA-TAVI. Methods: One hundred consecutive high-risk patients (mean age 79 ± 9 years, mean logistic EuroSCORE: 25.8 ± 17.6%) who underwent TA-TAVI in our center were included. The Edwards valve was used in all cases, and all procedures were performed in an operating room without hybrid facilities. The TA-TAVI was primarily guided by angiography in the first 25 patients (A-TAVI group) and by TEE in the last 75 patients (TEE-TAVI group). Procedural, 30-day, and follow-up results were evaluated. Results: No differences were observed between groups at baseline except for a higher (p = 0.001) prevalence of moderate or severe mitral regurgitation in the TEE-TAVI group. The procedure was successful in 97.3% and 100% of the patients in the TEE-TAVI and A-TAVI groups, respectively (p = 1.0), and a lower contrast volume was used in the TEE-TAVI group (12 [5 to 20] ml vs. 40 [20 to 50] ml, p < 0.0001). There were no differences between groups in the occurrence of valve malposition needing a second valve (TEE-TAVI: 5.3%; A-TAVI: 4%; p = 1.0) or valve embolization (TEE-TAVI: 1.3%; A-TAVI: 4%; p = 0.44). The results regarding post-procedural valve hemodynamic status and aortic regurgitation were similar between groups. The survival rates at 30-day and 1-year follow-up were 87% and 75% in the TEE-group and 88% and 84% in the A-TAVI group, respectively (log-rank = 0.49). Conclusions: TEE-TAVI was associated with similar acute and midterm results as A-TAVI and significantly reduced contrast media use during the procedures. These results suggest the feasibility and safety of performing TA-TAVI procedures in an operating room without hybrid facilities, but larger studies are needed to confirm these findings.
Effect of thoracic epidural analgesia on clinical outcomes following transapical transcatheter aortic valve implantation
2012-11-01, Lemieux, Jérôme, Carrasco, José Luis, Dumont, Éric, Rheault, Michel, Côté, Mélanie, Villeneuve, Jacques, Nombela-Franco, Luis, Rodés-Cabau, Josep, Amat Santos, Ignacio J., Simon, Mathieu, Lavigne, Dominique, Mok, Michael, Doyle, Daniel, Urena Alcazar, Marina, Pibarot, Philippe, Bourgault, Christine, Blackburn, Steve, Cohen, David J., St-Pierre, André, De Larochellière, Robert
OBJECTIVE: To determine the impact of perioperative thoracic epidural analgesia (TEA) on acute and late outcomes following transapical transcatheter aortic valve implantation (TA-TAVI). PATIENTS AND INTERVENTION: A total of 135 consecutive patients who underwent TA-TAVI were included. All patients received catheter-based pain control, either via TEA (TEA group, n=74) or intercostal local analgesia with a catheter placed at the surgical incision site (non-TEA group, n=61), depending on the preference of the anaesthesiologist responsible for the case. MAIN OUTCOME MEASURES: Pain level during early postoperative period (verbal rating scale from 1 to 10), 30-day/in-hospital complications and mortality, and 1-year mortality. RESULTS: There were no differences in baseline or procedural characteristics between groups except for a lower left ventricular ejection fraction in the TEA group. The maximal pain score related to thoracotomy in the postoperative period was higher in the non-TEA group as compared with the TEA group (4 (IQR: 3-5)) vs 2 (IQR: 1-3), p<0.001). Non-TEA was associated with a higher rate of pulmonary complications (p<0.05 for nosocomial pneumonia, reintubation and tracheostomy). The 30-day/in-hospital mortality rate was higher in the non-TEA group (22.9% vs 2.7% in the TEA group, p<0.001). At 1-year follow-up, overall mortality remained higher in the non-TEA group (31.1%) compared with the TEA group (10.8%), p=0.005. Similar periprocedural and late results were obtained in a propensity score-matched analysis that included 100 matched patients. In the multivariable analysis, STS score (p=0.027) and absence of TEA (p=0.039) were independent predictors of increased cumulative late mortality. CONCLUSIONS: TEA provided superior analgesia following TA-TAVI, and was associated with a dramatic reduction in periprocedural respiratory complications, and both, short- and long-term mortality. These results highlight the importance of obtaining optimal analgesia following TA-TAVI to improve the results associated with this procedure.