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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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  • PublicationRestreint
    Incidence, predictive factors, and prognostic value of myocardial injury following uncomplicated transcatheter aortic valve implantation.
    (Elsevier Biomedical, 2011-05-17) Bertrand, Olivier; Gutiérrez, Marcos; Dumont, Éric; De Larochellière, Robert; Larose, Éric; Côté, Mélanie; Villeneuve, Jacques; Rodés-Cabau, Josep; Bagur, Rodrigo Hernan; Doyle, Daniel; Manazzoni, Juan; Pibarot, Philippe
    OBJECTIVES: This study sought to: 1) determine the incidence, degree, and timing of the rise in serum cardiac markers of myocardial injury associated with uncomplicated transcatheter aortic valve implantation (TAVI); and 2) evaluate the predictive factors and prognostic value of myocardial injury associated with TAVI. BACKGROUND: Very few data exist on the occurrence and clinical relevance of myocardial injury during TAVI procedures. METHODS: A total of 101 patients who underwent successful TAVI (transfemoral [TF] approach, n = 38; transapical [TA] approach, n = 63) were included. Creatine kinase-MB (CK-MB) and cardiac troponin T (cTnT) levels were determined at baseline and at 6 to 12, 24, 48, and 72 h following TAVI. RESULTS: TAVI was associated with some degree of myocardial injury in 99% of the patients (TF: 97%, TA: 100%) as determined by a rise in cTnT (maximal value, 0.48 µg/l, interquartile range [IQR]: 0.24 to 0.82 µg/l) and in 77% of the patients (TF: 47%, TA: 95%) as determined by a rise in CK-MB (maximal value, 18.6 µg/l; IQR: 11.0 to 27.4 µg/l). TA approach and baseline renal dysfunction were associated with a higher increase in biomarkers of myocardial injury (p < 0.01 for both). A larger myocardial injury was associated with a smaller improvement of left ventricular ejection fraction (LVEF) (p < 0.01). The degree of rise in cTnT was an independent predictor of cardiac mortality at 9 ± 10 months of follow-up (hazard ratio: 1.14 per each increase of 0.1 µg/l, 95% confidence interval: 1.02 to 1.28, p = 0.028). CONCLUSIONS: TAVI was systematically associated with some degree of myocardial injury, with TA approach and baseline renal dysfunction determining a higher increase in biomarkers of myocardial injury. A greater degree of myocardial injury was associated with less improvement in LVEF and a higher cardiac mortality at follow-up.
  • PublicationRestreint
    Significant mitral regurgitation left untreated at the time of aortic valve replacement : a comprehensive review of a frequent entity in the transcatheter aortic valve replacement era.
    (Elsevier Biomedical, 2014-06-24) DeLarochellière, Hugo; Laflamme, Louis; Dumont, Éric; Côté, Mélanie; Nombela-Franco, Luis; Rodés-Cabau, Josep; Bergeron, Sébastien; Amat Santos, Ignacio J.; Beaudoin, Jonathan; Laflamme, Jérôme; García, Eulogio; Doyle, Daniel; Macaya, Carlos; Urena Alcazar, Marina; Jiménez-Quevedo, Pilar; Pibarot, Philippe; Allende, Ricardo; Ribeiro, Henrique B.; De Larochellière, Robert
    Significant mitral regurgitation (MR) is frequent in patients with severe aortic stenosis (AS). In these cases, concomitant mitral valve repair or replacement is usually performed at the time of surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) has recently been considered as an alternative for patients at high or prohibitive surgical risk. However, concomitant significant MR in this setting is typically left untreated. Moderate to severe MR after aortic valve replacement is therefore a relevant entity in the TAVR era. The purpose of this review is to present the current knowledge on the clinical impact and post-procedural evolution of concomitant significant MR in patients with severe AS who have undergone aortic valve replacement (SAVR and TAVR). This information could contribute to improving both the clinical decision-making process in and management of this challenging group of patients.
  • PublicationRestreint
    Acute kidney injury following transcatheter aortic valve implantation : predictive factors, prognostic value, and comparison with surgical aortic valve replacement
    (European Society of Cardiology, 2009-12-27) Bertrand, Olivier; Webb, John G. (John Graydon); Dumont, Éric; Nietlispach, Fabian; De Larochellière, Robert; Rodés-Cabau, Josep; Bagur, Rodrigo Hernan; Doyle, Daniel; Masson, Jean-Bernard; Pibarot, Philippe; Gutiérrez-Marcos, José; Clavel, Marie-Annick
    Aims: Very few data exist on the occurrence of acute kidney injury (AKI) associated with transcatheter aortic valve implantation (TAVI). The objectives of the present study were (i) to determine the incidence, predictive factors, and prognostic value of AKI following TAVI, and (ii) to compare the occurrence of AKI in TAVI vs. surgical aortic valve replacement (SAVR) in patients with pre-procedural chronic kidney disease (CKD). Methods and results: A total of 213 patients (mean age 82 ± 8 years) undergoing TAVI for the treatment of severe aortic stenosis were included in the study. Acute kidney injury was defined as a reduction of >25% in estimated glomerular filtration rate (eGFR) within 48 h following the procedure or the need for haemodialysis during index hospitalization. Those patients with pre-procedural CKD (eGFR <60 mL/min/1.73 m2, n = 119) were compared with 104 contemporary patients with CKD who underwent isolated SAVR. The incidence of AKI following TAVI was 11.7%, with 1.4% of the patients requiring haemodialysis. Predictive factors of AKI were hypertension (OR: 4.66; 95% CI: 1.04–20.87), chronic obstructive pulmonary disease (OR: 2.64, 95% CI: 1.10–6.36), and peri-operative blood transfusion (OR: 3.47, 95% CI: 1.30–9.29). Twenty-one patients (9.8%) died during index hospitalization, and the logistic EuroSCORE (OR: 1.03 for each increase of 1%; 95% CI: 1.01–1.06) and occurrence of AKI (OR: 4.14, 95% CI: 1.42–12.13) were identified as independent predictors of postoperative mortality. Patients with CKD who underwent TAVI were older, had a higher logistic EuroSCORE and lower pre-procedural eGFR values compared with those who underwent SAVR (P < 0.0001 for all). The incidence of AKI was lower (P = 0.001; P = 0.014 after propensity score adjustment) in CKD patients who underwent TAVI (9.2%, need for haemodialysis: 2.5%) compared with those who underwent SAVR (25.9%, need for haemodialysis: 8.7%). Conclusion: Acute kidney injury occurred in 11.7% of the patients following TAVI and was associated with a greater than four-fold increase in the risk of postoperative mortality. Hypertension, chronic obstructive pulmonary disease, and blood transfusion were predictive factors of AKI. In those patients with pre-procedural CKD, TAVI was associated with a significant reduction of AKI compared with SAVR.
  • PublicationAccès libre
    Myocardial injury following transcatheter aortic valve implantation : insights from delayed-enhancement cardiovascular magnetic resonance
    (CongrHealth.com, 2015-06-01) Dahou, Abdellaziz; Dumont, Éric; Paz Ricapito, Maria de la; De Larochellière, Robert; Larose, Éric; Nombela-Franco, Luis; Rodés-Cabau, Josep; Le Ven, Florent; Mohammadi, Siamak; Paradis, Jean-Michel; Capoulade, Romain; Amat Santos, Ignacio J.; Doyle, Daniel; Urena Alcazar, Marina; Pibarot, Philippe; Allende, Ricardo; Clavel, Marie-Annick; Ribeiro, Henrique B.
    Aims: The aim of this study was to evaluate the presence, localisation and extent of myocardial injury as determined by late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging in patients undergoing transcatheter aortic valve implantation (TAVI). Methods and results: A total of 37 patients, who underwent successful TAVI with a balloon-expandable valve (transapical [TA], n=11; non-TA, n=26), were included. Cardiac biomarker (CK-MB and cTnT) levels were determined at baseline and following TAVI. CMR was performed within a week before and within 30 days following TAVI. Some increase in cardiac biomarkers was detected in 97% of the patients as determined by a rise in cTnT, and in 49% of the patients as determined by a rise in CK-MB. Following TAVI, no new myocardial necrosis defects were observed with the non-TA approach. Nonetheless, all patients who underwent TAVI through the TA approach had new focal myocardial necrosis in the apex, with a median myocardial extent and necrotic mass of 5% [2.0-7.0] and 3.5 g [2.3-4.5], respectively. Conclusions: Although some increase in cardiac biomarkers of myocardial injury was systematically detected following TAVI, new myocardial necrosis as evaluated by CMR was observed only in patients undergoing the procedure through the TA approach, involving ~5% of the myocardium in the apex.
  • PublicationRestreint
    Chronic obstructive pulmonary disease in patients undergoing transcatheter aortic valve implantation : insights on clinical outcomes, prognostic markers, and functional status changes.
    (2013-08-01) DeLarochellière, Hugo; Laflamme, Louis; Dumont, Éric; Côté, Mélanie; Villeneuve, Jacques; Nombela-Franco, Luis; Rodés-Cabau, Josep; Amat Santos, Ignacio J.; Laflamme, Jérôme; Mok, Michael; Doyle, Daniel; Maltais, François; Urena Alcazar, Marina; Pibarot, Philippe; Allende, Ricardo; Ribeiro, Henrique B.; De Larochellière, Robert
    OBJECTIVES: This study sought to determine the effects of chronic obstructive pulmonary disease (COPD) on clinical outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) and to determine the factors associated with worse outcomes in COPD patients. BACKGROUND: No data exist on the factors determining poorer outcomes in COPD patients undergoing TAVI. METHODS: A total of 319 consecutive patients (29.5% with COPD) who underwent TAVI were studied. Functional status was evaluated by New York Heart Association (NYHA) functional class, Duke Activity Status Index, and the 6-min walk test (6MWT) at baseline and at 6 to 12 months. The TAVI treatment was considered futile if the patient either died or did not improve in NYHA functional class at 6-month follow-up. RESULTS: Survival rates at 1 year were 70.6% in COPD patients and 84.5% in patients without COPD (p = 0.008). COPD was an independent predictor of cumulative mortality after TAVI (hazard ratio: 1.84; 95% confidence interval: 1.08 to 3.13; p = 0.026). Improvement in functional status was observed after TAVI (p < 0.001 for NYHA functional class, Duke Activity Status Index, and 6MWT), but COPD patients exhibited less (p = 0.036) improvement in NYHA functional class. Among COPD patients, a shorter 6MWT distance predicted cumulative mortality (p = 0.013), whereas poorer baseline spirometry results (FEV1 [forced expiratory volume in the first second of expiration]) determined a higher rate of periprocedural pulmonary complications (p = 0.040). The TAVI treatment was futile in 40 COPD patients (42.5%) and a baseline 6MWT distance <170 m best determined the lack of benefit after TAVI (p = 0.002). CONCLUSIONS: COPD was associated with a higher rate of mortality at mid-term follow-up. Among COPD patients, a higher degree of airway obstruction and a lower exercise capacity determined a higher risk of pulmonary complications and mortality, respectively. TAVI was futile in more than one-third of the COPD patients, and a shorter distance walked at the 6MWT predicted the lack of benefit after TAVI. These results may help to improve the clinical decision-making process in this challenging group of patients
  • PublicationRestreint
    Need for permanent pacemaker as a complication of transcatheter aortic valve implantation and surgical aortic valve replacement in elderly patients with severe aortic stenosis and similar baseline electrocardiographic findings.
    (Elsevier, 2012-05-01) Dumont, Éric; Côté, Mélanie; Gurvitch, Ronen; Rodés-Cabau, Josep; Voisine, Pierre; Velianou, James L.; Bagur, Rodrigo Hernan; Toggweiler, Stefan; Doyle, Daniel; Cheung, Anson; Manazzoni, Juan; Ye, Jian; Philippon, François; Natarajan, Madhu K.; Pibarot, Philippe; Bainey, Kevin; Webb, John G. (John Graydon); De Larochellière, Robert
    Objectives: The aim of this study was to compare the incidence and predictive factors of complete atrioventricular block (AVB) and permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR). Background: No data exist on the need for PPI after TAVI versus SAVR in patients with similar baseline electrocardiographic (ECG) findings. Methods: A total of 411 patients with severe aortic stenosis (AS) and no prior pacemaker who underwent TAVI with the balloon-expandable Edwards valve (Edwards Lifesciences, Irvine, California) were matched (1:1) with 411 elderly patients with severe AS who underwent isolated SAVR on the basis of baseline ECG findings. The incidence, reasons, and predictive factors for PPI within 30 days after the procedure were compared between groups. Results: Mean age was similar in both groups (p = 0.11), and the TAVI group had a higher Society of Thoracic Surgeons score (p < 0.001). The rate of new PPI was higher after TAVI (7.3%) compared with SAVR (3.4%), p = 0.014. Complete AVB and severe symptomatic bradycardia, respectively, were the reasons for PPI in the TAVI (5.6% and 1.7%, respectively) and SAVR (2.7% and 0.7%, respectively) groups (p = 0.039 for complete AVB, p = NS for symptomatic bradycardia). The presence of baseline right bundle branch block was the only variable associated with PPI in the TAVI group (odds ratio: 8.61, 95% confidence interval: 3.14 to 23.67, p < 0.0001), whereas no variable was found in the SAVR group. Conclusions: Transcatheter aortic valve implantation was associated with a higher rate of complete AVB and PPI compared with SAVR in elderly patients with severe AS and similar baseline ECG findings. The presence of baseline right bundle branch block correlated with the need for PPI in the TAVI group.
  • PublicationRestreint
    Prognostic 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
  • PublicationAccès libre
    Incidence, 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, Robert
    Aims: 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.
  • PublicationRestreint
    Predictive 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, Robert
    OBJECTIVES: 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.
  • PublicationRestreint
    Long-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, Robert
    OBJECTIVES: 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.