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Rodés-Cabau, Josep

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  • PublicationRestreint
    Rate, timing, correlates, and outcomes of hemodynamic valve deterioration after bioprosthetic surgical aortic valve replacement
    (American Heart Association, 2018-08-13) Mahjoub, Haïfa; Rodés-Cabau, Josep; Kalavrouziotis, Dimitri; Voisine, Pierre; Mohammadi, Siamak; Côté, Nancy; Yanagawa, Bobby; Girerd, Nicolas; Pibarot, Philippe; Juni, Peter; Clavel, Marie-Annick; Verma, Subodh; Puri, Rishi; Dagenais, François; Mathieu, Patrick; Salaun, Erwan
    Background: The incidence of structural valve deterioration after bioprosthesis (BP) aortic valve replacement (AVR) established on the basis of reoperation may substantially underestimate the true incidence. The objective is to determine the rate, timing, correlates, and association between hemodynamic valve deterioration (HVD) and outcomes assessed by Doppler echocardiography after surgical BP AVR. Methods: A total of 1387 patients (62.2% male, 70.5±7.8 years of age) who underwent BP AVR were included in this retrospective study. Baseline echocardiography was performed at a median time of 4.1 (1.3–6.5) months after AVR. All patients had an echocardiographic follow-up ≥2 years after AVR (926 at least 5 years and 385 at least 10 years). HVD was defined by Doppler assessment as a ≥10 mm Hg increase in mean gradient or worsening of transprosthetic regurgitation ≥1/3 class. HVD was classified according to the timing after AVR: “very early,” during the first 2-years; “early,” between 2 and 5 years; “midterm,” between 5 and 10 years; and “long-term,” >10 years. Results: A total of 428 patients (30.9%) developed HVD. Among these patients, 52 (12.0%) were classified as “very early,” 129 (30.1%) as “early,” 158 (36.9%) as “midterm,” and 89 (20.8%) as “long-term” HVD. Factors independently associated with HVD occurring within the first 5 years after AVR were diabetes mellitus (P=0.01), active smoking (P=0.01), renal insufficiency (P=0.01), baseline postoperative mean gradient ≥15 mm Hg (P=0.04) or transprosthetic regurgitation ≥mild (P=0.04), and type of BP (stented versus stentless, P=0.003). Factors associated with HVD occurring after the fifth year after AVR were female sex (P=0.03), warfarin use (P=0.007), and BP type (P<0.001). HVD was independently associated with mortality (hazard ratio, 2.18; 95% CI, 1.86–2.57; P<0.001). Conclusions: HVD as identified by Doppler echocardiography occurred in one third of patients and was associated with a 2.2-fold higher adjusted mortality. Diabetes mellitus and renal insufficiency were associated with early HVD, whereas female sex, warfarin use, and stented BPs (versus stentless) were associated with late HVD.
  • PublicationAccès libre
    Sex-related differences in Low-Gradient, low-ejection fraction aortic stenosis results from the multicenter TOPAS study
    (ScienceDirect, 2019-01-07) Bartko, Philipp Emanuel; Dahou, Abdellaziz; Rodés-Cabau, Josep; Annabi, Mohamed Salah; Pibarot, Philippe; Clavel, Marie-Annick
  • PublicationRestreint
    B-Type natriuretic peptide and high-sensitivity cardiac troponin for risk stratification in low-flow, low-gradient aortic stenosis a substudy of the TOPAS study
    (American College of Cardiology Foundation, 2017-10-05) Dahou, Abdellaziz; O'Connor, Kim; Rodés-Cabau, Josep; Le Ven, Florent; Côté, Nancy; Capoulade, Romain; Pibarot, Philippe; Dumesnil, Jean G.; Clavel, Marie-Annick; Ribeiro, Henrique B.; Mathieu, Patrick
    OBJECTIVES: The objective of this study was to determine the prognostic value of combined measures of B-type natriuretic peptide (BNP) and high-sensitivity cardiac troponin T (hsTnT) in patients with low-flow, low-gradient aortic stenosis (LF-LG AS) who had either a preserved or reduced left ventricular ejection fraction (LVEF). BACKGROUND: An elevated BNP level is associated with increased risk of mortality in patients with LF-LG AS. The incremental prognostic value of hsTnT in these patients is unknown. METHODS: Ninety-eight patients (74 10 years; 75% men) with LF-LG AS (LVEF <50% and/or stroke volume index <35 ml/m2 , mean gradient <40 mm Hg, indexed aortic valve area <0.6 cm2 /m2 ) who were prospectively enrolled in the TOPAS (Truly or Pseudo-Severe Aortic Stenosis) study were included. The cohort was divided into 3 groups according to BNP and hsTnT levels: group A: BNP <550 pg/ml and hsTnT <15 ng/l; group B: BNP $550 pg/ml or hsTnT $15 ng/l; and group C: BNP $550 pg/ml and hsTnT $15 ng/l. The primary endpoint was all-cause mortality. RESULTS: Twenty-seven patients (27%) were in group A, 39 (40%) were in group B, and 32 (33%) were in group C. During a median follow-up of 2.8 years, 43 patients died. Two-year mortality was higher in group C (41 9%) than in group B (23 7%) and group A (5 4%) (p ¼ 0.002). In group B, there was no significant difference in 2-year mortality rates between the subgroup with hsTnT $15 ng/l (n ¼ 29) and the subgroup with BNP $550 pg/ml (n ¼ 10) (26 9% vs. 11 10%, respectively; p ¼ 0.21). In multivariable analysis adjusted for age, type of treatment (aortic valve replacement vs. conservative therapy), coronary artery disease, and LVEF, being in group C remained independently associated with an increased risk of mortality (hazard ratio [HR]: 4.25; p ¼ 0.023), and group B tended to have higher mortality (HR: 3.63; p ¼ 0.058) compared with group A. CONCLUSIONS: This study demonstrated the usefulness of combined measures of BNP and hsTnT to enhance risk stratification in patients with LF-LG AS. Patients with elevation of both BNP and hsTnT had a markedly increased risk of mortality. (Multicenter Prospective Study of Low-Flow Low-Gradient Aortic Stenosis [TOPAS]; NCT01835028)
  • PublicationAccès libre
    Relationship between QT interval and outcome in low-flow low-gradient aortic stenosis with low left ventricular ejection fraction
    (John Wiley & Sons, 2016-10-20) Dahou, Abdellaziz; Toubal, Oumhani; Larose, Éric; Magne, Julien; Rodés-Cabau, Josep; Beaudoin, Jonathan; Philippon, François; Pibarot, Philippe; Dumesnil, Jean G.; Clavel, Marie-Annick; Puri, Rishi; Mathieu, Patrick; Ribeiro, Henrique B.
    Background QT interval has been shown to be associated with cardiovascular events. There is no data regarding the association between QT interval and left ventricular (LV) function and prognosis in patients with low LV ejection fraction (LVEF), low‐flow, low‐gradient aortic stenosis (LF‐LG AS). We aimed to examine the relationship between corrected QT interval (QTc) and LV function and outcome in these patients. Methods and Results Ninety‐three patients (73±10 years; 74% men) with LF‐LG AS (mean gradient <40 mm Hg and indexed aortic valve area ≤0.6 cm2/m2) and reduced LVEF (≤40%) were prospectively included in this analysis and 63 of them underwent aortic valve replacement within 3 months following inclusion. Prolonged QTc was defined as QTc >450 ms in men and >470 ms in women. LV global longitudinal strain was measured by speckle tracking and expressed in absolute value |%|. QTc correlated with the following: global longitudinal strain (r=−0.40, P=0.005), LVEF (r=−0.27, P=0.02), stroke volume (r=−0.35, P=0.007), and B‐type natriuretic peptide (r=0.45, P=0.0006). During a median follow‐up of 2.0 years, 49 patients died. Prolonged QTc was associated with a 2‐fold increase in all‐cause mortality (hazard ratio=2.05; P=0.01) and cardiovascular mortality (hazard ratio=1.89; P=0.04). In multivariable analysis adjusted for EuroSCORE, aortic valve replacement, previous myocardial infarction, LVEF, and ß‐blocker medication, prolonged QTc was independently associated with all‐cause mortality (hazard ratio=2.56; P=0.008) and cardiovascular mortality (hazard ratio=2.50; P=0.02). Conclusions In patients with LF‐LG AS and reduced LVEF, longer QTc interval was associated with worse LV function and increased risk of death. Assessment of QTc may provide a simple and inexpensive tool to enhance risk stratification in LF‐LG AS patients.
  • PublicationAccès libre
    Hemodynamic deterioration of surgically implanted bioprosthetic aortic valves
    (Elsevier Biomedical, 2018-07-09) Dahou, Abdellaziz; Arsenault, Benoit; Larose, Éric; Mahjoub, Haïfa; Rodés-Cabau, Josep; Pibarot, Philippe; Clavel, Marie-Annick; Puri, Rishi; Després, Jean-Pierre; Mathieu, Patrick; Salaun, Erwan
    BACKGROUND: Dysmetabolic profile has been associated with native aortic valve stenosis. However, there are imited data on the effects of an atherogenic milieu and its potential implications on the structural and hemodynamic deterio- ration of aortic bioprosthetic valves. OBJECTIVES: This prospective longitudinal study sought to determine the predictors and impact on outcomes of he- modynamic valve deterioration (HVD) of surgically implanted aortic bioprostheses. METHODS: A total of 137 patients with an aortic bioprosthesis implanted for a median time of 6.7 (interquartile range: 5.1 to 9.1) years prospectively underwent a first (baseline) assessment with complete Doppler echocardiography, quantitation of bioprosthesis leaflet calcification by multidetector computed tomography (CT), and a fasting blood sample to assess cardiometabolic risk profile. All patients underwent a second (follow-up) Doppler echocardiography examination at 3 (interquartile range: 2.9 to 3.3) years post-baseline visit. HVD was defined by an annualized change in mean transprosthetic gradient $3 mm Hg/year and/or worsening or transprosthetic regurgitation by $1/3 class. The primary endpoint was a nonhierarchical composite of death from any cause or aortic reintervention procedure (redo surgical valve replacement or transcatheter valve-in-valve implantation) for bioprosthesis failure. RESULTS Thirty-four patients (25.6%) had leaflet calcification on baseline CT, and 18 patients (13.1%) developed an HVD between baseline and follow-up echocardiography. Fifty-two patients (38.0%) met the primary endpoint during subsequent follow-up after the second echocardiographic examination. Leaflet calcification (hazard ratio [HR]: 2.58; 95% confidence interval [CI]: 1.35 to 4.82; p ¼ 0.005) and HVD (HR: 5.12; 95% CI: 2.57 to 9.71; p < 0.001) were independent predictors of the primary endpoint. Leaflet calcification, insulin resistance (homeostatic model assessment index $2.7), lipoprotein-associated phospholipase A2 activity (Lp-PLA2 per 0.1 nmol/min/ml increase), and high level of proprotein convertase subtilisin/kexin 9 (PCSK9) ($305 ng/ml) were associated with the development of HVD after adjusting for age, sex, and time interval since aortic valve replacement. CONCLUSIONS: HVD identified by Doppler echocardiography is independently associated with a marked increase in the risk of valve reintervention or mortality in patients with a surgical aortic bioprosthesis. A dysmetabolic profile charac- terized by elevated plasma Lp-PLA2, PCSK9, and homeostatic model assessment index was associated with increased risk of HVD. The presence of leaflet calcification as detected by CT was a strong predictor of HVD, providing incremental risk- predictive capacity. (J Am Coll Cardiol 2018;72:241–51) © 2018 by the American College of Cardiology Foundation.
  • PublicationAccès libre
    Haemodynamic outcomes following aortic valve-in-valve procedure
    (BMJ Publishing Group, 2018-07-09) Dahou, Abdellaziz; Guzzetti, Ezequiel; Dumont, Éric; De Larochellière, Robert; Côté, Mélanie; Rodés-Cabau, Josep; Mohammadi, Siamak; Paradis, Jean-Michel; Doyle, Daniel; Zenses, Anne-Sophie; Pibarot, Philippe; Clavel, Marie-Annick; Ong, Géraldine; Chamandi, Chekrallah; Salaun, Erwan; Rodriguez-Gabella, Tania; Rieu, Régis
    Background and objectives: Transcatheter aortic valve- in-valve implantation (ViV) has emerged as a valuable technique to treat failed surgical bioprostheses (BPs) in patients with high risk for redo surgical aortic valve replacement (SAVR). Small BP size (≤21 mm), stenotic pattern of degeneration and pre-existing prosthesis– patient mismatch (PPM) have been associated with worse clinical outcomes after ViV. However, no study has evaluated the actual haemodynamic benefit associated with ViV. This study aims to compare haemodynamic status observed at post-ViV, pre-ViV and early after initial SAVR and to determine the factors associated with worse haemodynamic outcomes following ViV, including the rates of high residual gradient and ‘haemodynamic futility’. Methods: Early post-SAVR, pre-ViV and post-ViV echocardiographic data of 79 consecutive patients who underwent aortic ViV at our institution were retrospectively analysed. The primary study endpoint was suboptimal valve haemodynamics (SVH) following ViV defined by the Valve Academic Research Consortium 2 as the presence of high residual aortic mean gradient (≥20 mm Hg) and/or at least moderate aortic regurgitation (AR). Haemodynamic futility of ViV was defined as <10 mm Hg decrease in mean aortic gradient and no improvement in AR compared with pre-ViV. Results: SVH was found in 61% of patients (57% high residual gradient, 4% moderate AR) after ViV versus 24% early after SAVR. Pre-existing PPM and BP mode of failure by stenosis were independently associated with the primary endpoint (OR: 2.87; 95% CI 1.08 to 7.65; p=0.035 and OR: 3.02; 95% CI 1.08 to 8.42; p=0.035, respectively) and with the presence of high residual gradient (OR: 4.38; 95% CI 1.55 to 12.37; p=0.005 and OR: 5.37; 95% CI 1.77 to 16.30; p=0.003, respectively) following ViV. Criteria of ViV haemodynamic futility were met in 7.6% overall and more frequently in patients with pre-existing PPM and stenotic BP (18.5%) compared with other patients (2.0%). ViV restored haemodynamic function to early post-SAVR level in only 34% of patients. Conclusion: Although ViV was associated with significant haemodynamic improvement compared with pre-ViV in >90% of patients, more than half harboured SVH outcome. Furthermore, only one-third of patients had a restoration of valve haemodynamic function to the early post-SAVR level. Pre-existing PPM and stenosis pattern of BP degeneration were the mian factors associated with SVH and haemodynamic futility following ViV. These findings provide strong support for the prevention of PPM at the time of initial SAVR and careful preprocedural patient screening.
  • PublicationAccès libre
    Bioprosthetic aortic valve durability in the era of transcatheter aortic valve implantation
    (B M J Group, 2018-05-07) Rodés-Cabau, Josep; Pibarot, Philippe; Clavel, Marie-Annick; Salaun, Erwan
    The main limitation of bioprosthetic valves is their limited durability, which exposes the patient to the risk of aortic valve reintervention. Transcatheter aortic valve implantation (TAVI) is considered a reasonable alternative to surgical aortic valve replacement (SAVR) in patients with intermediate or high surgical risk. TAVI is now rapidly expanding towards the lower risk populations. Although the results of midterm durability of the transcatheter bioprostheses are encouraging, their long-term durability remains largely unknown. The objective of this review article is to present the definition, mechanisms, incidence, outcome and management of structural valve deterioration of aortic bioprostheses with specific emphasis on TAVI. The structural valve deterioration can be categorised into three stages: stage 1: morphological abnormalities (fibrocalcific remodelling and tear) of bioprosthesis valve leaflets without hemodynamic valve deterioration; stage 2: morphological abnormalities and moderate hemodynamic deterioration (increase in gradient and/or new onset of transvalvular regurgitation); and stage 3: morphological abnormalities and severe hemodynamic deterioration. Several specifics inherent to the TAVI including valve oversizing, manipulation, delivery, positioning and deployment may cause injuries to the valve leaflets and increase leaflet mechanical stress, which may limit the long-term durability of transcatheter bioprostheses. The selection of the type of aortic valve replacement and bioprosthesis should thus take into account the ratio between the demonstrated durability of the bioprostheses versus the life expectancy of the patient. Pending the publication of robust data on long-term durability of transcatheter bioprostheses, it appears reasonable to select SAVR with a bioprosthesis model that has well-established long-term durability in patients with low surgical risk and long life expectancy.
  • PublicationRestreint
    Outcomes from transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis and left ventricular ejection fraction less than 30% : a substudy from the TOPAS-TAVI registry
    (JAMA Network, 2018-12-19) Maes, Frédéric; Dahou, Abdellaziz; Lerakis, Stamatios A.; Côté, Mélanie; Nombela-Franco, Luis; Gilard, Martine; Rodés-Cabau, Josep; Cavalcante, João L.; Annabi, Mohamed Salah; Makkar, Rajendra; Pelletier Beaumont, Émilie; Herrmann, Howard C.; Pibarot, Philippe; Windecker, Stephan; Clavel, Marie-Annick; Enriquez-Sarano, Maurice; Puri, Rishi; Cheema, Asim; Ribeiro, Henrique B.; Muñoz, Antonio; García del Blanco, Bruno; Zajarias, Alan; Lisko, John C.; Hayek, Salim; Babaliaros, Vasilis; Le Ven, Florent; Gleason, Thomas G.; Chakravarty, Tarun; Szeto, Wilson; Agustin, Alberto de; Serra, Vicenç; Schindler, John Thomas
    Importance: In low-flow, low-gradient aortic stenosis (LFLG AS), the severity of left ventricular dysfunction remains a key factor in the evaluation of aortic valve replacement. Objective: To evaluate the clinical outcomes and changes in left ventricular ejection fraction (LVEF) after transcatheter aortic valve replacement (TAVR) in patients with LFLG AS and severe left ventricular dysfunction. Design, setting, and participants: This multicenter registry is a substudy of the True or Pseudo-Severe Aortic Stenosis-TAVI registry that included patients with classic LFLG AS, defined as a mean transvalvular gradient less than 35 mm Hg, an effective orifice area less than 1.0 cm2, and an LVEF of 40% or less. Patients were divided in groups with very low (<30%) LVEF and low (30%-40%) LVEF. Dobutamine stress echocardiography (DSE) was performed before TAVR in a subset with very low LVEF, and presence of contractile reserve was defined as an increase of 20% or more in stroke volume. Clinical outcomes were assessed at 1 and 12 months and yearly thereafter, and echocardiography was performed at 1-year follow-up. Retrospective data were collected from 2007 to 2013 and prospective data from January 2013 to March 2018. Data were analyzed from March to October 2018. Exposures: Transcatheter aortic valve replacement in patients with LFLG AS. Main outcomes and measures: Changes in LVEF over time; periprocedural and late mortality. Results: A total of 293 patients were included, including 128 (43.7%) with very low LVEF and 165 with low LVEF (56.3%). Their mean (SD) age was 80 (7) years, and most (214 [73.0%]) were men. The mean (SD) LVEF in the very low LVEF group was 22% (5%), compared with 37% (7%) in the low LVEF group (P < .001). There were no differences between groups in rates of periprocedural mortality and late mortality (median [interquartile range], 23 [6-38] months). Patients with very low LVEF displayed a greater increase in LVEF at the 1-year follow-up examination (mean absolute increase, 11.9% [95% CI, 8.8%-15.1%]), than the low LVEF group (3.6% [95% CI, 1.1%-6.1%]; P < .001). In 92 patients with very low LVEF who had preprocedural DSE, results showed a lack of contractile reserve in 45 (49%), but this had no effect on clinical outcomes or changes in LVEF over time. Conclusions and relevance: In patients with LFLG AS and severe left ventricular dysfunction, TAVR was associated with similar clinical outcomes as in counterparts with milder left ventricular dysfunction. The TAVR procedure was associated with a significant increase in LVEF, irrespective of contractile reserve. These results support TAVR for LFLG AS, irrespective of the severity of left ventricular dysfunction and DSE results.
  • PublicationAccès libre
    Valve-in-valve procedure in failed transcatheter aortic valves
    (Elsevier, 2018-05-16) Dumont, Éric; De Larochellière, Robert; Rodés-Cabau, Josep; Rodriguez-Gabella, Tania; Mohammadi, Siamak; Paradis, Jean-Michel; Doyle, Daniel; Zenses, Anne-Sophie; Pibarot, Philippe; Clavel, Marie-Annick; Salaun, Erwan
  • PublicationRestreint
    Transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis : the TOPAS-TAVI registry
    (Elsevier Science, 2018-03-19) Dahou, Abdellaziz; Lerakis, Stamatios A.; Côté, Mélanie; Gilard, Martine; Nombela-Franco, Luis; Cavalcante, João L.; Rodés-Cabau, Josep; Makkar, Rajendra; Le Ven, Florent; Herrmann, Howard C.; Amat Santos, Ignacio J.; Windecker, Stephan; Pelletier Beaumont, Émilie; Enriquez-Sarano, Maurice; Pibarot, Philippe; Cheema, Asim; Clavel, Marie-Annick; Puri, Rishi; Ribeiro, Henrique B.; Muñoz, Antonio; García del Blanco, Bruno; Zajarias, Alan; Lisko, John C.; Hayek, Salim; Babaliaros, Vasilis; Gleason, Thomas G.; Chakravarty, Tarun; Szeto, Wilson Y.; Agustin, Alberto de; Serra, Vicenç; Schindler, John Thomas
    Background : Few data exist on patients with low-flow, low-gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR). Also, very scarce data exist on the usefulness of dobutamine stress echocardiography (DSE) before TAVR in these patients. Objectives : The authors sought to evaluate clinical outcomes and changes in left ventricular ejection fraction (LVEF) following TAVR in patients with classical LFLG-AS. Methods : This multicenter registry included 287 patients with LFLG-AS undergoing TAVR. DSE was performed before TAVR in 234 patients and the presence of contractile reserve was defined as an increase of ≥20% in stroke volume. Transthoracic echocardiography was repeated at hospital discharge and at 1-year follow-up. Clinical follow-up was obtained at 1 and 12 months, and yearly thereafter. Results : The median Society of Thoracic Surgeons score of the study population was 7.7% (interquartile range 5.3% to 12.0%), and the mean LVEF and transvalvular gradient were 30.1 ± 9.7% and 25.4 ± 6.6 mm Hg, respectively. The presence of contractile reserve was observed in 45% of patients at DSE. Mortality rates were 3.8%, 20.1%, and 32.3% at 30 days, 1 year, and 2 years, respectively. On multivariable analysis, chronic obstructive pulmonary disease (p = 0.022) and lower hemoglobin values (p < 0.001) were associated with all-cause mortality. Lower hemoglobin values (p = 0.004) and moderate-to-severe aortic regurgitation post-TAVR (p = 0.018) were predictors of the composite of mortality and rehospitalization due to heart failure. LVEF increased by 8.3% (95% confidence interval: 6% to 11%) at 1-year follow-up, and the lack of prior coronary artery bypass graft (p = 0.004), a lower LVEF at baseline (p < 0.001), and a lower stroke volume index at baseline (p = 0.019) were associated with greater increase in LVEF. The absence of contractile reserve at baseline DSE was not associated with any negative effect on clinical outcomes or LVEF changes at follow-up. Conclusions : TAVR was associated with good periprocedural outcomes in patients with LFLG-AS. However, approximately one-third of LFLG-AS TAVR recipients died at 2-year follow-up, with pulmonary disease, anemia, and residual paravalvular leaks associated with poorer outcomes. LVEF improved following TAVR, but DSE failed to predict clinical outcomes or LVEF changes over time. (Multicenter Prospective Study of Low-Flow Low-Gradient Aortic Stenosis [TOPAS Study]; NCT01835028)