Personne : De Larochellière, Robert
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De Larochellière
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Robert
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Université Laval. Département de médecine
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- PublicationRestreintCerebral embolism following transcatheter aortic valve implantation : comparison of transfemoral and transapical approaches.(Elsevier Biomedical, 2011-01-04) Bédard, Fernand; Dumont, Éric; Boone, Robert H.; De Larochellière, Robert; Larose, Éric; Côté, Mélanie; Gurvitch, Ronen; Villeneuve, Jacques; Rodés-Cabau, Josep; Bagur, Rodrigo Hernan; Doyle, Daniel; Jayasuria, Cleonie; Pibarot, Philippe; Marrero, Alier; Webb, John G. (John Graydon)OBJECTIVES: The objective of this study was to compare the incidence of cerebral embolism (CE) as evaluated by diffusion-weighted magnetic resonance imaging (DW-MRI) following transapical (TA) transcatheter aortic valve implantation (TAVI) versus transfemoral (TF) TAVI. BACKGROUND: The TA-TAVI approach avoids both the manipulation of large catheters in the aortic arch/ascending aorta and the retrograde crossing of the aortic valve, and this avoidance might lead to a lower rate of CE. METHODS: This was a prospective multicenter study including 60 patients who underwent cerebral DW-MRI the day before and within the 6 days following TAVI (TF approach: 29 patients; TA approach: 31 patients). Neurologic and cognitive function assessments were performed at DW-MRI time points. RESULTS: The TAVI procedure was performed with the Edwards valve and was successful in all cases but one (98%). A total of 41 patients (68%) had 251 new cerebral ischemic lesions at the DW-MRI performed 4 ± 1 days after the procedure, 19 patients in the TF group (66%) and 22 patients in the TA group (71%; p = 0.78). Most patients (76%) with new ischemic lesions had multiple lesions (median number of lesions per patient: 3, range 1 to 31). There were no differences in lesion number and size between the TF and TA groups. No baseline or procedural factors were found to be predictors of new ischemic lesions. The occurrence of CE was not associated with a measurable impairment in cognitive function, but 2 patients (3.3%) had a clinically apparent stroke within the 24 h following the procedure (1 patient in each group). CONCLUSIONS: TAVI is associated with a high rate of silent cerebral ischemic lesions as evaluated by DW-MRI, with no differences between the TF and TA approaches. These results provide important novel insight into the mechanisms of CE associated with TAVI and support the need for further research to both reduce the incidence of CE during these procedures and better determine their clinical relevance
- PublicationAccès libreIncidence, predictive factors and haemodynamic consequences of acute stent recoil following transcatheter aortic valve implantation with a balloon-expandable valve(Europa Edition, 2014-04-01) DeLarochellière, Hugo; Laflamme, Louis; Dumont, Éric; Larose, Éric; Côté, Mélanie; Nombela-Franco, Luis; Rodés-Cabau, Josep; Laflamme, Jérôme; Pasian, Sergio; Doyle, Daniel; Urena Alcazar, Marina; Pibarot, Philippe; Allende, Ricardo; Ribeiro, Henrique B.; Jerez-Valero, Miguel; De Larochellière, RobertAims: The elastic behaviour (acute recoil) of a valve prosthesis stent following transcatheter aortic valve implantation (TAVI) is unknown. This study sought to determine the occurrence, severity, predictive factors and haemodynamic consequences of acute recoil following TAVI. Methods and results : A prospective angiographic analysis of the stent frame dimensions in 111 consecutive patients who underwent TAVI with a balloon-expandable valve (36 Edwards SAPIEN; 75 SAPIEN XT) was performed. Acute recoil was defined as the difference between minimal lumen diameter (MLD) at full balloon expansion and immediately after balloon deflation. MLD during balloon inflation was significantly larger than MLD after balloon deflation (23.40±2.31 mm vs. 22.29±2.21 mm, p<0.001), which represented an absolute and percent decrease in stent dimension of 1.10±0.40 mm and 4.70±1.76%, respectively. In the multivariate analysis, the predictors of larger recoil were a higher prosthesis/annulus ratio (r²=0.0624, p=0.015) and the SAPIEN XT prosthesis (r²=0.1276, p=0.001). No significant changes in haemodynamic performance were observed at discharge and follow-up in patients with larger recoil. Conclusions : TAVI with a balloon-expandable valve was systematically associated with a certain degree of valve stent recoil after balloon deflation. A higher degree of valve oversizing and the SAPIEN XT prosthesis predicted a larger degree of stent recoil.
- PublicationRestreintPrognostic value of exercise capacity as evaluated by the 6-minute walk test in patients undergoing transcatheter aortic valve implantation(Elsevier, 2013-02-26) DeLarochellière, Hugo; Laflamme, Louis; Dumont, Éric; Côté, Mélanie; Nombela-Franco, Luis; Rodés-Cabau, Josep; Mok, Michael; Doyle, Daniel; Poirier, Paul; Urena Alcazar, Marina; Pibarot, Philippe; Ribeiro, Henrique B.; De Larochellière, Robert
- PublicationRestreintComparison of hemodynamic performance of self-expandable CoreValve versus balloon-expandable Edwards SAPIEN aortic valves inserted by catheter for aortic stenosis(Elsevier, 2013-04-01) Dumont, Éric; Ruel, Marc; Nombela-Franco, Luis; Radhakrishnan, Sam; Rodés-Cabau, Josep; Webb, John G. (John Graydon); Hansen, Marc; Mok, Michael; Labinaz, Marino; Doyle, Daniel; Thompson, Chris; Urena Alcazar, Marina; Fremes, Stephen; Pibarot, Philippe; Dumesnil, Jean G.; Ribeiro, Henrique B.; Roifman, Idan; Watkins, Stuart; De Larochellière, RobertTranscatheter aortic valve implantation with the self-expandable Core Valve (CV) and the balloon-expandable Edwards SAPIEN (ES) bioprostheses has been widely used for the treatment of severe aortic stenosis. However, a direct comparison of the hemodynamic results associated with these 2 prostheses is lacking. The aim of the present study was to compare the hemodynamic performance of both bioprostheses. A total of 41 patients who underwent transcatheter aortic valve implantation with the CV prosthesis were matched 1:1 for prosthesis size (26 mm), aortic annulus size, left ventricular ejection fraction, body surface area, and body mass index with patients who underwent transcatheter aortic valve implantation with the ES prosthesis. Doppler-echocardiographic data were prospectively collected before the intervention and at hospital discharge, and all examinations were sent to, and analyzed in, a central echocardiography core laboratory. The mean transprosthetic residual gradient was lower (p = 0.024) in the CV group (7.9 +/- 3.1 mm Hg) than in the ES group (9.7 +/- 3.8 mm Hg). The effective orifice area tended to be greater in the CV group (1.58 +/- 0.31 cm(2) vs 1.49 +/- 0.24 cm(2), p = 0.10). The incidence of severe prosthesis patient mismatch was, however, similar between the 2 groups (effective orifice area indexed to the body surface area <= 0.65 cm(2)/m(2); CV 9.8%, ES 9.8%, p = 1.0). The incidence of paravalvular aortic regurgitation was greater with the CV (grade 1 or more in 85.4%, grade 2 or more in 39%) than with the ES (grade 1 or more in 58.5%, grade 2 or more in 22%; p = 0.001). The number and extent of paravalvular leaks were greater in the CV group (p < 0.01 for both comparisons). In conclusion, transcatheter aortic valve implantation with the CV prosthesis was associated with a lower residual gradient but a greater rate of paravalvular aortic regurgitation compared to the ES prosthesis. The potential clinical consequences of the differences in hemodynamic performance between these transcatheter heart valves needs to be addressed in future studies.
- PublicationRestreintLong-term outcomes after transcatheter aortic valve implantation : insights on prognostic factors and valve durability from the Canadian multicenter experience(Elsevier Biomedical, 2012-11-06) Dumont, Éric; Webb, John G. (John Graydon); Rodés-Cabau, Josep; Cheung, Anson; Jeansoulin, Robert; Ye, Jian; Doyle, Daniel; Osten, Mark; Pibarot, Philippe; Feindel, Christopher M.; Dumesnil, Jean G.; Natarajan, Madhu K.; Velianou, James L.; Martucci, Giussepe; De Varennes, Benoît; Peterson, Mark; Thompson, Chris; Wood, David A.; Toggweiler, Stefan; Gurvitch, Ronen; Lichtenstein, Samuel V.; Teoh, Kevin; Chu, Victor; Bainey, Kevin; Lachapelle, Kevin; Cheema, Asim; Latter, David; Horlick, Eric; De Larochellière, RobertOBJECTIVES: This study sought to evaluate the long-term outcomes after transcatheter aortic valve implantation (TAVI) in the Multicenter Canadian Experience study, with special focus on the causes and predictors of late mortality and valve durability. BACKGROUND: Very few data exist on the long-term outcomes associated with TAVI. METHODS: This was a multicenter study including 339 patients considered to be nonoperable or at very high surgical risk (mean age: 81 ± 8 years; Society of Thoracic Surgeons score: 9.8 ± 6.4%) who underwent TAVI with a balloon-expandable Edwards valve (transfemoral: 48%, transapical: 52%). Follow-up was available in 99% of the patients, and serial echocardiographic exams were evaluated in a central echocardiography core laboratory. RESULTS: At a mean follow-up of 42 ± 15 months 188 patients (55.5%) had died. The causes of late death (152 patients) were noncardiac (59.2%), cardiac (23.0%), and unknown (17.8%). The predictors of late mortality were chronic obstructive pulmonary disease (hazard ratio [HR]: 2.18, 95% confidence interval [CI]: 1.53 to 3.11), chronic kidney disease (HR: 1.08 for each decrease of 10 ml/min in estimated glomerular filtration rate, 95% CI: 1.01 to 1.19), chronic atrial fibrillation (HR: 1.44, 95% CI: 1.02 to 2.03), and frailty (HR: 1.52, 95% CI: 1.07 to 2.17). A mild nonclinically significant decrease in valve area occurred at 2-year follow-up (p < 0.01), but no further reduction in valve area was observed up to 4-year follow-up. No changes in residual aortic regurgitation and no cases of structural valve failure were observed during the follow-up period. CONCLUSIONS: Approximately one-half of the patients who underwent TAVI because of a high or prohibitive surgical risk profile had died at a mean follow-up of 3.5 years. Late mortality was due to noncardiac comorbidities in more than one-half of patients. No clinically significant deterioration in valve function was observed throughout the follow-up period.
- PublicationRestreintPredictive factors and long-term clinical consequences of persistent left bundle branch block following transcatheter aortic valve implantation with a balloon-expandable valve(Elsevier Biomedical, 2012-10-03) Dumont, Éric; Larose, Éric; Serra, Vicenç; Côté, Mélanie; Nombela-Franco, Luis; Rodés-Cabau, Josep; Amat Santos, Ignacio J.; Igual, Albert; Mok, Michael; Doyle, Daniel; Philippon, François; Urena Alcazar, Marina; Cuéllar, Hug; Pibarot, Philippe; Jaegere, Peter de; García del Blanco, Bruno; De Larochellière, RobertOBJECTIVES: This study evaluated the predictive factors and prognostic value of new-onset persistent left bundle branch block (LBBB) in patients undergoing transcatheter aortic valve implantation (TAVI) with a balloon-expandable valve. BACKGROUND: The predictors of persistent (vs. transient or absent) LBBB after TAVI with a balloon-expandable valve and its clinical consequences are unknown. METHODS: A total of 202 consecutive patients with no baseline ventricular conduction disturbances or previous permanent pacemaker implantation (PPI) who underwent TAVI with a balloon-expandable valve were included. Patients were on continuous electrocardiographic (ECG) monitoring during hospitalization and 12-lead ECG was performed daily until hospital discharge. No patient was lost at a median follow-up of 12 (range: 6 to 24) months, and ECG tracing was available in 97% of patients. The criteria for PPI were limited to the occurrence of high-degree atrioventricular block (AVB) or severe symptomatic bradycardia. RESULTS: New-onset LBBB was observed in 61 patients (30.2%) after TAVI, and had resolved in 37.7% and 57.3% at hospital discharge and 6- to 12-month follow-up, respectively. Baseline QRS duration (p = 0.037) and ventricular depth of the prosthesis (p = 0.017) were independent predictors of persistent LBBB. Persistent LBBB at hospital discharge was associated with a decrease in left ventricular ejection fraction (p = 0.001) and poorer functional status (p = 0.034) at 1-year follow-up. Patients with persistent LBBB and no PPI at hospital discharge had a higher incidence of syncope (16.0% vs. 0.7%; p = 0.001) and complete AVB requiring PPI (20.0% vs. 0.7%; p < 0.001), but not of global mortality or cardiac mortality during the follow-up period (all, p > 0.20). New-onset LBBB was the only factor associated with PPI following TAVI (p < 0.001). CONCLUSIONS: Up to 30% of patients with no prior conduction disturbances developed new LBBB following TAVI with a balloon-expandable valve, although it was transient in more than one third. Longer baseline QRS duration and a more ventricular positioning of the prosthesis were associated with a higher rate of persistent LBBB, which in turn determined higher risks for complete AVB and PPI, but not mortality, at 1-year follow-up.
- PublicationRestreintEffect of thoracic epidural analgesia on clinical outcomes following transapical transcatheter aortic valve implantation(BMJ, 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, RobertOBJECTIVE: 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.
- PublicationRestreintPredictive factors, efficacy, and safety of balloon post-dilation after transcatheter aortic valve implantation with a balloon-expandable valve(Elsevier, 2012-05-21) Dumont, Éric; Larose, Éric; Rheault, Michel; Côté, Mélanie; Villeneuve, Jacques; Nombela-Franco, Luis; Rodés-Cabau, Josep; Bergeron, Sébastien; Amat Santos, Ignacio J.; Mok, Michael; Doyle, Daniel; Bernier, Mathieu; Urena Alcazar, Marina; Pibarot, Philippe; Dumesnil, Jean G.; De Larochellière, RobertOBJECTIVES: This study sought to evaluate the predictive factors, effects, and safety of balloon post-dilation (BPD) for the treatment of significant paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI). BACKGROUND: Very few data exist on BPD after TAVI with a balloon-expandable valve. METHODS: A total of 211 patients who underwent TAVI with a balloon-expandable valve were included. BPD was performed after TAVI if paravalvular AR [Greater-than or equal to] 2 was identified by transesophageal echocardiography. Clinical events and echocardiographic data were prospectively recorded, and median follow-up was 12 (6 to 24) months. RESULTS: BPD was performed in 59 patients (28%), leading to a reduction in at least 1 degree of AR in 71% of patients, with residual AR <2 in 54% of the patients. The predictors of the need for BPD were the degree of valve calcification and transfemoral approach, with valve calcification volume >2,200 and >3,800 mm(3) best determining the need for and a poor response to BPD, respectively. Patients who underwent BPD had a higher incidence of cerebrovascular events at 30 days (11.9% vs. 2.0%, p = 0.006), with most (83%) events within the 24 h after the procedure occurring in patients who had BPD. No significant changes in valve area or AR degree were observed at follow-up in BPD and no-BPD groups. CONCLUSIONS: BPD was needed in about one-fourth of the patients undergoing TAVI with a balloon-expandable valve and was successful in about one-half of them. A higher degree of valve calcification and transfemoral approach predicted the need for BPD. BPD was not associated with any deleterious effect on valve function at mid-term follow-up, but a higher rate of cerebrovascular events was observed in patients who had BPD.
- PublicationRestreintIncidence, predictive factors, and prognostic value of new-onset atrial fibrillation following transcatheter aortic valve implantation(Elsevier, 2012-01-10) Dumont, Éric; Côté, Mélanie; Villeneuve, Jacques; Nombela-Franco, Luis; Rodés-Cabau, Josep; Amat Santos, Ignacio J.; Bagur, Rodrigo Hernan; Doyle, Daniel; Philippon, François; Urena Alcazar, Marina; Pibarot, Philippe; De Larochellière, RobertObjectives: This study sought to evaluate the incidence, predictive factors, and prognostic value of new-onset atrial fibrillation (NOAF) following transcatheter aortic valve implantation (TAVI). Background: Very few data exist on the occurrence of NOAF following TAVI. Methods: A total of 138 consecutive patients with no prior history of atrial fibrillation (AF) underwent TAVI with a balloon-expandable valve. Patients were on continuous electrocardiogram monitoring until hospital discharge, and NOAF was defined as any episode of AF lasting >30 s. All clinical, echocardiographic, procedural, and follow-up data were prospectively collected. Results: NOAF occurred in 44 patients (31.9%) at a median time of 48 h (interquartile range: 0 to 72 h) following TAVI. The predictive factors of NOAF were left atrial (LA) size (odds ratio [OR]: 1.21 for each increase in 1 mm/m2, 95% confidence interval [CI]: 1.09 to 1.34, p < 0.0001) and transapical approach (OR: 4.08, 95% CI: 1.35 to 12.31, p = 0.019). At 30-day follow-up, NOAF was associated with a higher rate of stroke/systemic embolism (13.6% vs. 3.2%, p = 0.021, p = 0.047 after adjustment for baseline differences between groups), with no differences in mortality rate between groups (NOAF: 9.1%, no-NOAF: 6.4%, p = 0.57). At a median follow-up of 12 months (interquartile range: 5 to 20 months), a total of 27 patients (19.6%) had died, with no differences between the NOAF (15.9%) and no-NOAF (21.3%) groups, p = 0.58. The cumulative rate of stroke and stroke/systemic embolism at follow-up were 13.6% and 15.9%, respectively, in the NOAF group versus 3.2% in the no-NOAF group (p = 0.039, adjusted p = 0.037 for stroke; p = 0.020, adjusted p = 0.023 for stroke/systemic embolism). Conclusions: NOAF occurred in about one-third of the patients with no prior history of AF undergoing TAVI and its incidence was increased in patients with larger LA size and those undergoing transapical TAVI. NOAF was associated with a higher rate of stroke/systemic embolism, but not a higher mortality, at 30 days and at 1-year follow-up.
- PublicationRestreintPredicting late myocardial recovery and outcomes in the early hours of ST-segment elevation myocardial infarction : traditional measures compared with microvascular obstruction, salvaged myocardium, and necrosis characteristics by cardiovascular magnetic resonance(Elsevier, 2010-06-01) Bertrand, Olivier; Noël, Bernard; Woerly, Stéphane; De Larochellière, Robert; Boudreault, Jean-Roch; Larose, Éric; Rodés-Cabau, Josep; Barbeau, Gérald; Nguyen, Can Manh; Rouleau, Jacques; Proulx, Guy; Amyot, Marc; Déry, Jean-Pierre; Pibarot, Philippe; Roy, Louis; Gleeton, OnilObjectives : The aim of this study was to determine whether a very early imaging strategy improves the prediction of late systolic dysfunction and poor outcomes in ST-segment elevation myocardial infarction (STEMI) compared with traditional predictors. Background : Earlier prediction of poor outcomes after STEMI is desirable, because it will allow tailored therapy at the earliest possible time, when benefits might be greatest. Methods : One hundred and three patients with acute STEMI were studied by contrast-enhanced cardiovascular magnetic resonance within 12 h of primary angioplasty and at 6 months and followed >2 years. The primary end point was left ventricular (LV) dysfunction, whereas poor outcomes were a key secondary end point. Results : Traditional risk factors were only modest predictors of late LV dysfunction. Late gadolinium enhancement (LGE) volume maintained a stronger association to LV ejection fraction change than infarct transmurality, microvascular obstruction, or myocardial salvage during STEMI (p = 0.02). Multivariable logistic regression identified LGE volume during STEMI as the best predictor of late LV dysfunction (odds ratio: 1.36, p = 0.03). An LGE =23% of LV during STEMI accurately predicted late LV dysfunction (sensitivity 89%, specificity 74%). The LGE volume provided important incremental benefit for predicting late dysfunction (area under the curve = 0.92, p = 0.03 vs. traditional risk factors). Twenty-three patients developed poor outcomes (1 death, 2 myocardial infarctions, 5 malignant arrhythmias, 4 severe LV dysfunction <35%, 11 hospital stays for heart failure) over 2.6 ± 0.9 years; LGE volume remained a strong independent predictor of poor outcomes, whereas LGE =23% carried a hazard ratio of 6.1 for adverse events (p < 0.0001). Conclusions : During the hyperacute phase of STEMI, LGE volume provides the strongest association and incremental predictive value for late systolic dysfunction and discerns poor late outcomes.