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Clavel, Marie-Annick

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Clavel

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Marie-Annick

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Université Laval. Faculté de médecine

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Voici les éléments 1 - 10 sur 72
  • PublicationAccès libre
    Impact of vascular hemodynamics on aortic stenosis evaluation : new insights into the pathophysiology of normal flow - small aortic valve area - low gradient pattern
    (John Wiley & Sons, 2017-07-07) Clisson, Marine; Shen, Mylène; Côté, Nancy; Zenses, Anne-Sophie; Clavel, Marie-Annick; Tastet, Lionel; Simard, Louis
    Background: About 50% of normal‐flow/low‐gradient patients (ie, low mean gradient [MG] or peak aortic jet velocity and small aortic valve area) have severe aortic valve calcification as measured by computed tomography. However, they are considered to have moderate aortic stenosis (AS) in current American College of Cardiology/American Heart Association guidelines. The objective was thus to evaluate the effect of hypertension and reduced arterial compliance (rAC) on MG and Vpeak measurements. Methods and Results: Doppler‐echocardiography was performed in 4 sheep with experimentally induced severe and critical AS at: (1) normal aortic pressure, (2) during hypertension, and (3) with rAC. Hypertension and rAC induced a substantial decrease in MG/Vpeak compared with normal stage (both P≤0.03) despite a stable transvalvular flow (P>0.16). Hypertension and rAC resulted in a greater reduction of MG in critical (−42%) compared with severe (−35%) AS (P˂0.0001). Comprehensive Doppler‐echocardiography and computed tomography were performed in 220 AS patients (mean age: 69±13 years; MG 29±18 mm Hg) with normal flow. The population was divided in 3 groups according to the presence of hypertension and rAC. The slope of the linear association between MG/Vpeak and aortic valve calcification divided by the cross‐sectional area of the aortic annulus was significantly reduced in patients with hypertension and/or rAC compared with normotensive/normal AC patients (P<0.01). Accordingly, patients with normal‐flow/low‐gradient and severe aortic valve calcification density were more frequent in hypertension and rAC groups compared with the normotensive/normal‐AC group (16% and 12% compared with 2%; P=0.03). Conclusions: Hypertension and rAC are associated with a substantial reduction in MG/Vpeak for similar aortic valve calcification (ie, similar AS anatomic severity), which may lead to underestimation of AS hemodynamic severity
  • PublicationRestreint
    Low-flow aortic stenosis : flow rate does not replace but could refine stroke volume index
    (American College of Cardiology Foundation, 2021-03-17) Annabi, Mohamed Salah; Clavel, Marie-Annick
  • PublicationAccès libre
    Dobutamine stress echocardiography for management of low-flow, low-gradient aortic stenosis
    (Elsevier Biomedical, 2018-01-29) Dahou, Abdellaziz; Larose, Éric; Annabi, Mohamed Salah; Burwash, Ian G.; Touboul, Eden; Bergler-Klein, Jutta; Pibarot, Philippe; Enriquez-Sarano, Maurice; Clavel, Marie-Annick; Orwat, Stefan; Baumgartner, Helmut; Mascherbauer, Julia; Mundigler, Gerald; Cavalcante, João L.
    Background: Dobutamine stress echocardiography (DSE) is useful to differentiate true from pseudo severe aortic stenosis in patients with low left ventricular ejection fraction (LVEF), low-flow, low-gradient aortic stenosis (LF-LG AS). In the ACC/AHA guidelines, patients are considered having true-severe stenosis when the mean gradient (MG) is ≥40mmHg with an aortic valve area (AVA) ≤1cm2 during DSE. However these criteria have not been previously validated. The aim of this study was to assess the value of these criteria to predict the presence of true-severe AS and the occurrence of death in patients with LFLG AS. Methods: In the TOPAS (“True or Pseudo-Severe Aortic Stenosis”) study, 186 patients with low LVEF LF-LG AS were prospectively recruited and underwent DSE with measurement of the MG, AVA and projected AVA, an estimate of the AVA at a standardized normal flow rate (AVAProj). Severity of AS was independently corroborated by macroscopic evaluation of the valve at the time of valve replacement in 54 patients and by measurement of the aortic valve calcium by computed tomography in 25 patients and by both methods in 8. According to these assessments, 50/87 (57%) of the study cohort had true-severe stenosis. Results: Peak stress MG ≥40 mmHg, peak stress AVA ≤1cm2, and the combination of peak stress MG ≥40 mmHg and peak stress AVA≤1cm2 correctly classified AS severity in 48%, 60%, and 47% of patients, respectively, whereas AVAProj ≤1cm2 was better than all the previous markers (p<0.007) with 70% of correct classification. Among the subset of 88 patients managed conservatively (47% of cohort), 52 died during a follow-up of 2.8±2.5 years. After adjustment for age, sex, functional capacity, chronic kidney failure and peak stress LVEF, peak stress MG and AVA were not predictors of mortality in this subset. In contrast, AVAProj ≤1cm2 was a strong predictor of mortality under medical management (HR: 3.65; p=0.0003). Conclusion: In patients with low LVEF LF-LG AS, the DSE criteria of peak stress MG≥40 mmHg, or the composite of peak stress MG≥40 mmHg and peak stress AVA≤1cm2 proposed in the guidelines to identify true-severe AS and recommend valve replacement, have limited value to predict actual stenosis severity and outcomes. In contrast, AVAProj better distinguishes true from pseudo-severe aortic stenosis and is strongly associated with mortality in patients under conservative management.
  • PublicationAccès libre
    Performance of computed tomographic angiography–based aortic valve area for assessment of aortic stenosis
    (Wiley-Blackwell Publishing, 2023-08-10) Ash, Jerry; Sandhu, Gurmandeep S.; Arriola-Montenegro, Jose; Agakishiev, Dzhalal; Clavel, Marie-Annick; Pibarot, Philippe; Duval, Sue; Nijjar, Prabhjot S.
    Background A total of 40% of patients with severe aortic stenosis (AS) have low‐gradient AS, raising uncertainty about AS severity. Aortic valve calcification, measured by computed tomography (CT), is guideline‐endorsed to aid in such cases. The performance of different CT‐derived aortic valve areas (AVAs) is less well studied. Methods and Results Consecutive adult patients with presumed moderate and severe AS based on echocardiography (AVA measured by continuity equation on echocardiography <1.5 cm2) who underwent cardiac CT were identified retrospectively. AVAs, measured by direct planimetry on CT (AVACT) and by a hybrid approach (AVA measured in a hybrid manner with echocardiography and CT [AVAHybrid]), were measured. Sex‐specific aortic valve calcification thresholds (≥1200 Agatston units in women and ≥2000 Agatston units in men) were applied to adjudicate severe or nonsevere AS. A total of 215 patients (38.0% women; mean±SD age, 78±8 years) were included: normal flow, 59.5%; and low flow, 40.5%. Among the different thresholds for AVACT and AVAHybrid, diagnostic performance was the best for AVACT <1.2 cm2 (sensitivity, 85%; specificity, 26%; and accuracy, 72%), with no significant difference by flow status. The percentage of patients with correctly classified AS severity (correctly classified severe AS+correctly classified moderate AS) was as follows; AVA measured by continuity equation on echocardiography <1.0 cm2, 77%; AVACT <1.2 cm2, 73%; AVACT <1.0 cm2, 58%; AVAHybrid <1.2 cm2, 59%; and AVAHybrid <1.0 cm2, 45%. AVACT cut points of 1.52 cm2 for normal flow and 1.56 cm2 for low flow, provided 95% specificity for excluding severe AS. Conclusions CT‐derived AVAs have poor discrimination for AS severity. Using an AVACT <1.2‐cm2 threshold to define severe AS can produce significant error. Larger AVACT thresholds improve specificity.
  • 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
    Moderate aortic stenosis in patients with heart failure and reduced ejection
    (Elsevier Biomedical, 2021-05-31) Jean, Guillaume; Bernard, Jérémy; Van Mieghem, Nicolas M.; Pibarot, Philippe; Gegenava, Tea; Clavel, Marie-Annick; Van Gils, Lennart; Geleijnse, Marcel L.; Vollema, E. Mara; El Azzouzi, Ikram; Spitzer, Ernest; Delgado, Victoria; Bax, Jeroen J.
    Background: The study investigators previously reported that moderate aortic stenosis (AS) is associated with a poor prognosis in patients with heart failure (HF) with reduced left ventricular ejection fraction (LVEF) (HFrEF). However, the respective contribution of moderate AS versus HFrEF to the outcomes of these patients is unknown. Objectives: This study sought to determine the impact of moderate AS on outcomes in patients with HFrEF. Methods: The study included 262 patients with moderate AS (aortic valve area >1.0 and <1.5 cm2; and peak aortic jet velocity >2 and <4 m/s, at rest or after dobutamine stress echocardiography) and HFrEF (LVEF <50%). These patients were matched 1:1 for sex, age, estimated glomerular filtration rate, New York Heart Association functional class III to IV, presence of diabetes, LVEF, and body mass index with patients with HFrEF but no AS (i.e., peak aortic jet velocity <2 m/s). The endpoints were all-cause mortality and the composite of death and HF hospitalization. Results: A total of 262 patients with HFrEF and moderate AS were matched with 262 patients with HFrEF and no AS. Mean follow-up was 2.9 ± 2.2 years. In the moderate AS group, mean aortic valve area was 1.2 ± 0.2 cm2, and mean gradient was 14.5 ± 4.7 mm Hg. Moderate AS was associated with an increased risk of mortality (hazard ratio [HR]: 2.98; 95% confidence interval [CI]: 2.08 to 4.31; p < 0.0001) and of the composite of HF hospitalization and mortality (HR: 2.34; 95% CI: 1. 72 to 3.21; p < 0.0001). In the moderate AS group, aortic valve replacement (AVR) performed in 44 patients at a median follow-up time of 10.9 ± 16 months during follow-up was associated with improved survival (HR: 0.59; 95% CI: 0.35 to 0.98; p = 0.04). Notably, surgical AVR was not significantly associated with improved survival (p = 0.92), whereas transcatheter AVR was (HR: 0.43; 95% CI: 0.18 to 1.00; p = 0.05). Conclusions: In this series of patients with HFrEF, moderate AS was associated with a marked incremental risk of mortality. AVR, and especially transcatheter AVR during follow-up, was associated with improved survival in patients with HFrEF and moderate AS. These findings provide support to the realization of a randomized trial to assess the effect of early transcatheter AVR in patients with HFrEF and moderate AS.
  • PublicationAccès libre
    How do we reconcile echocardiography, computed tomography, and hybrid imaging in assessing discordant grading of aortic stenosis severity?
    (Elsevier, 2019-02-04) Delgado, Victoria; Pibarot, Philippe; Clavel, Marie-Annick; Hahn, Rebecca T.; Gillam, Linda; Bax, Jeroen; Sengupta, Partho P.
    Up to 40% of patients with aortic stenosis (AS) present with a “discordant grading” usually referred to as “low-gradient AS.” This article presents a step-by-step integrative approach overview of the utility, limitations, and complementary role of the different imaging modalities for the assessment of AS severity with a special emphasis on the reconciliation of discordant grading. The first step is to confirm the validity of echocardiographic measures of AS severity. For example, hybrid imaging can combine left ventricular outflow tract area measured by 3-dimensional echocardiography or contrast enhanced multidetector row computed tomography with flow velocities measured by Doppler. The next step is to differentiate severe from non-severe AS with the use of low-dose dobutamine stress echocardiography, especially in patients with low left ventricular ejection fraction, low-flow, low-gradient AS. Aortic valve calcium scoring measured by noncontrast multidetector row computed tomography is preferred in patients with low-gradient AS and preserved left ventricular ejection fraction as well as in those with inconclusive results with dobutamine stress echocardiography.
  • PublicationAccès libre
    Balloon aortic valvuloplasty as a palliative treatment in patients with severe aortic stenosis and limited life expectancy : a single center experience
    (Agency, 2020-08-27) Mantovani, Francesca; Clavel, Marie-Annick; Potenza, Antonella; Leuzzi, Chiara; Grimaldi, Teresa; Vignal, Luigi; Navazio, Alessandro; Guiducci, Vincenzo
    Whether balloon aortic valvuloplasty (BAV) may provide an effective palliation in symptomatic high-risk patients is uncertain. Therefore, we aimed to evaluate outcomes in symptomatic high-risk patients with severe aortic stenosis (AS), who underwent BAV. All-cause mortality and length of hospitalization for heart failure (HF) up to death or to 1-year follow up were collected after BAV. One hundred thirty-two (132) patients (62% women), mean age 85±7 years, underwent BAV with a substantial reduction of the peak-to-peak aortic gradient from 53±21 to 29±15 mmHg (p<0.001). The median of days of HF hospitalization prior to BAV was 9 (0-19), and decreased after BAV to 0 (0-9), p<0.001. During 1-year follow-up patients with untreated CAD (85, 64%) had a higher mortality compared to patients with insignificant/treated CAD (47, 36%): 1-year survival: 45±7% vs. 66± 7%; p=0.02. After adjustment for STS risk score and severity of residual AS, patients with untreated CAD remained at higher risk of mortality (adjusted HR 1.74 [1.01-2.91]; p=0.04). Thus, in this series of symptomatic high-risk patients, BAV was associated with a significant reduction in aortic valve gradient and hospitalization time for HF post-BAV. In patients with significant CAD, percutaneous intervention might be considered in order to improve survival.
  • PublicationAccès libre
    Workup and management of patients with paradoxical low-flow, low-gradient aortic stenosis
    (Current Science Inc., 2018-05-02) Clisson, Marine; Annabi, Mohamed Salah; Pibarot, Philippe; Clavel, Marie-Annick
    About 60% of patients with paradoxical low-flow, low-gradient (PLF-LG) aortic stenosis (AS) have a severe disease that justifies aortic valve replacement (AVR). The first step in patients with symptomatic PLF AS should be to rule out measurement errors and treat hypertension. The second step is to distinguish pseudo-severe from true severe AS (TSAS). The third step is to select the optimal treatment modality at the right time. Regarding the second step, projected aortic valve area calculated using stress echocardiography is superior to traditional severity criteria (AVA G 1.0 cm2 and mean gradient ≥ 40 mmHg) to unmask TSAS and predict outcomes. Aortic valve calcification score quantitated by computed tomography is helpful to identify TSAS by applying thresholds of 2000 and 1200 AU, respectively, for men and women. This modality should be considered, partic- ularly if stress echocardiography is either not feasible or inconclusive. Once AS severity is confirmed, a risk stratification based on symptomatic status and the importance of left ventricular (LV) systolic impairment will guide therapeutic decision. Symptomatic assess- ment should not solely rely on patient-reported symptom status, but rather include an objective exercise test. The presence of symptomatic PLF-LG TSAS is a class IIa indication for AVR in the guidelines. In asymptomatic patients, a markedly reduced stroke volume, the presence of myocardial fibrosis by cardiac magnetic resonance imaging, a poor longitudinal LV function as assessed by speckle tracking echocardiography, and/or a moderate to severe LV diastolic dysfunction are predictors of poor outcome in PLF-LG patients and may indicate the need of early AVR. The type of AVR should be discussed within a multidisciplinary team, bearing in mind that transcatheter AVR (TAVR) is superior to medical treatment in inoperable patients. Furthermore, TAVR may be a useful alterna- tive to surgical AVR (SAVR) in high-risk patients. Nevertheless, the potential benefits of TAVR, including the lower risk of severe patient-prosthesis mismatch, should be weighed against the risk of paravalvular regurgitation, which is likely poorly tolerated by patients with PLF-LG who often harbor a small and non-compliant LV cavity.
  • PublicationAccès libre
    Imaging and impact of myocardial fibrosis in aortic stenosis
    (American College of Cardiology Foundation, 2019-02-04) Bing, Rong; Clavel, Marie-Annick; Cavalcante, João L.; Everett, Russell J.; Newby, David E.; Dweck, Marc R.
    Aortic stenosis is characterized both by progressive valve narrowing and the left ventricular remodeling response that ensues. The only effective treatment is aortic valve replacement, which is usually recommended in patients with severe stenosis and evidence of left ventricular decompensation. At present, left ventricular decompensation is most frequently identified by the development of typical symptoms or a marked reduction in left ventricular ejection fraction <50%. However, there is growing interest in using the assessment of myocardial fibrosis as an earlier and more objective marker of left ventricular decompensation, particularly in asymptomatic patients, where guidelines currently rely on non- randomized data and expert consensus. Myocardial fibrosis has major functional consequences, is the key pathological process driving left ventricular decompensation, and can be divided into 2 categories. Replacement fibrosis is irreversible and identified using late gadolinium enhancement on cardiac magnetic resonance, while diffuse fibrosis occurs earlier, is potentially reversible, and can be quantified with cardiac magnetic resonance T1 mapping techniques. There is a substantial body of observational data in this field, but there is now a need for randomized clinical trials of myocardial imaging in aortic stenosis to optimize patient management. This review will discuss the role that myocardial fibrosis plays in aortic stenosis, how it can be imaged, and how these approaches might be used to track myocardial health and improve the timing of aortic valve replacement.