Cardiac valvular surgery and history of anorectic drug intake: A retrospective study of a large population of benfluorex-exposed patients.

BACKGROUND: Anorectic drugs are overlooked as a cause of valvular heart disease (VHD). AIM: To describe the characteristics of a large population of patients with severe VHD who underwent cardiac surgery and had a history of benfluorex intake. METHODS: Retrospective observational and cross-sectional study of patients from a large French database (Office National d'Indemnisation des Accidents Médicaux). Clinical, echocardiographic, surgical and pathology findings were comprehensively collected from medical files. RESULTS: From a chart review of 9584 subjects, 1031 patients with VHD underwent cardiac surgery; 453 surgical patients were excluded because of VHD obviously unrelated to benfluorex exposure, six because of missing data and eight declined to participate. The final study population comprised 564 patients who had surgery between 1987 and 2019. Median age was 58 (interquartile range 50-65) years; 85% were female. Median duration of preoperative benfluorex exposure was 5.8 (3.3-10) years. Most patients had aortic and mitral valve disease. Pure or predominant aortic and/or mitral regurgitation were found in 84% of patients (n=471), and aortic or mitral stenosis (pure or combined with regurgitation) in 12% (n=67) and 15% (n=84), respectively. Overall, 403 aortic, 402 mitral and 64 tricuspid valve surgical procedures were collected. Aortic and mitral valves were found to be thickened, rigid and/or restrictive in most cases; restrictive tricuspid valve disease was seldom documented. Pathology was available in half of the population (276 patients); valvular fibrosis suggestive of drug-induced VHD was found in 222 patients, including 146 with expert examination. Mixed VHD aetiologies were discussed in 107 patients, including 54 with available pathology. CONCLUSIONS: Drug-induced VHD features are miscellaneous, including well-known restrictive valvular regurgitation, but also stenosis or combined regurgitation and stenosis. Besides a history of drug taking, thorough echocardiography and comprehensive surgical reports, pathology is key in the diagnostic procedure.

Watchful waiting care or early intervention in asymptomatic severe aortic stenosis: Where we are.

Aortic stenosis, the most common valvular heart disease in Western countries, affects predominantly older people. Prompt aortic valve replacement is undoubtedly indicated in symptomatic patients. Management of asymptomatic patients is nowadays shifting from a conservative approach to early aortic valve replacement, as multimodality imaging is increasingly available. However, multimodality imaging has led to multiple prognostic parameters and complex algorithms, as well as a new staging classification that has left patients and physicians somewhat puzzled. We highlight the value of thorough serial clinical examinations, Doppler echocardiography and exercise testing when caring for a growing aortic stenosis population, including that has no or limited access to multimodality imaging. Evidence for early aortic valve replacement versus conservative management in asymptomatic patients with severe aortic stenosis is biased by the lack of serial stress testing evaluation; 30% of so-called asymptomatic patients were in fact symptomatic, and thus were clear candidates for aortic valve replacement in the above-mentioned studies. Randomized trials of aortic valve replacement versus conservative management that include serial stress testing evaluation are needed to ascertain whether early aortic valve replacement actually improves clinical outcome in asymptomatic patients with severe aortic stenosis. Less interventional medicine and healthcare resource utilization can result in better health.

[How to detect myocardial ischemia in patients following acute coronary syndrome treated by PCI?] / Quel dépistage de l'ischémie myocardique après angioplastie dans le syndrome coronaire aigu ?

Unstable coronary artery disease is a more aggressive condition than stable coronary artery disease, accounting for the high incidence of major adverse cardiovascular events following acute coronary syndromes (ACS), which includes the need for iterative repeat revascularization. The aim of myocardial ischemia screening in post-ACS patients is to detect this unfavourable evolution (either on initial culprit or non culprit lesions) and to prevent any clinical complication. Although there is no strict recommendation in this particular situation, screening should be based on the use of stress imaging techniques. The optimal timing and frequency for testing will depend on the clinical characteristics of the patients and the coronary revascularization procedure features.

Long-term results of external aortic ring annuloplasty for aortic valve repair.

OBJECTIVES: An untreated dilated aortic annulus is a major risk factor for failure of aortic valve-sparing operations or repair of either bicuspid or tricuspid valve. Aortic annuloplasty efficiently reduces the annulus and increases the coaptation height, thus protecting the repair. This study analyses long-term results of 232 consecutive patients operated on with a standardized and physiological approach to aortic valve repair according to each phenotype of the dystrophic ascending aorta. Subvalvular aortic annuloplasty was systematically added using an external aortic ring to reduce annulus diameter when ≥25 mm. METHODS: Data were collected into the multicentric international AVIATOR registry (AorticValve repair InternATiOnal Registry): 149 patients with root aneurysm underwent remodelling with an external ring; 21 patients with tubular aortic aneurysm underwent supracoronary grafts with an external open ring and 62 patients with isolated aortic insufficiency (AI) underwent double sub- and/or supravalvular external open ring annuloplasty. Preoperative AI ≥ Grade III was present in 58.6% (133), and the valve was bicuspid in 37.9% (88). RESULTS: Cusp repair was performed in 75.4% (175) patients. The 30-day operative mortality rate was 1.4% (3). The mean follow-up was 40.1 ± 37.8 months (0-145.5). The actuarial survival rate at 7 years was 89.9%. The rate of freedom from reoperation at 7 years was similar among each phenotype, being 90.5% for root aneurysms, 100% for tubular aortic aneurysms and 97.5% for isolated AI with no difference between the bicuspid and tricuspid valve. The rates of freedom from AI ≥ Grade 2 and from AI ≥ Grade 3 at 7 years were, respectively, 76.0 and 93.1% for root aneurysms, 92.9 and 100% for tubular aortic aneurysms and 57.3 and 82.2% for isolated AI. Eye balling repair achieved suboptimal valve competency when compared with systematic cusp effective height assessment, which tended to improve the rate freedom from reoperation, respectively, from 85.8 ± 5.5% to 98.9 ± 1.1% and the rate of freedom from AI ≥ Grade 3 from 89.8 ± 4.9% to 100%. For isolated AI, an additional sinotubular junction ring (double sub- and supravalvular annuloplasty) tended to reduce recurrent AI when compared with single subvalvular annuloplasty. CONCLUSIONS: External aortic ring annuloplasty provides a reproducible technique for aortic valve repair with satisfactory long-term results for each ascending aorta phenotype with bicuspid or tricuspid valve. Longer follow-up is ongoing with the AVIATOR registry.

Drug-induced aortic valve stenosis: An under recognized entity.

BACKGROUND: We have been intrigued by the observation that aortic stenosis (AS) may be associated with characteristic features of mitral drug-induced valvular heart disease (DI-VHD) in patients exposed to valvulopathic drugs, thus suggesting that beyond restrictive heart valve regurgitation, valvulopathic drugs may be involved in the pathogenesis of AS. METHODS: Herein are reported echocardiographic features, and pathological findings encountered in a series of patients suffering from both AS (mean gradient >15mmHg) and mitral DI-VHD after valvulopathic drugs exposure. History of rheumatic fever, chest radiation therapy, systemic disease or bicuspid aortic valve disease were exclusion criteria. RESULTS: Twenty-five (19 females, mean age 62years) patients having both AS and typical features of mitral DI-VHD were identified. Mean transaortic pressure gradient was 32+/-13mmHg. Aortic regurgitation was ≥ mild in 24 (96%) but trivial in one. Known history of aortic valve regurgitation following drug initiation prior the development of AS was previously diagnosed in 17 patients (68%). Six patients underwent aortic valve replacement and 3 both aortic and mitral valve replacement. In the 9 patients with pathology analysis, aortic valvular endocardium was markedly thickened by dense non-inflammatory fibrosis, a characteristic feature of DI-VHD. CONCLUSION: The association between AS and typical mitral DI-VHD after valvulopathic drug exposure may not be fortuitous. Aortic regurgitation was usually associated to AS and preceded AS in most cases but may be lacking. Pathology demonstrated the potential role of valvulopathic drugs in the development of AS.

Multiple Fibroelastoma: Search and You Will Find.

Fibroelastoma is a rare cardiac tumor. Even more rare is multilocalization of these tumors as well as their residence inside the cardiac chambers. Here, the case is reported of a 46-year-old male with three fibroelastomas of which only two were diagnosed preoperatively. The third tumor was discovered during surgery on the endocardium of the left ventricular wall, 2 cm away from the base of the anterolateral papillary muscle after a thorough examination of the ventricle had been instituted. Emphasis must be placed on the importance of performing such an examination during the excision of fibroelastomas, as a failure to address multiple lesions - although their existence is rare - might expose the patient to dangers of future embolization or reoperation.

An expansible aortic ring to preserve aortic root dynamics after aortic valve repair.

OBJECTIVES: Aortic annuloplasty and preservation of root dynamics have been described as factors for durability of aortic valve repair. The objective of this study is to document the first clinical analysis of root dynamics after a standardized valve-sparing procedure for root aneurysms associating a calibrated expansible external aortic ring annuloplasty with a physiological remodelling of the aortic root (CAVIAAR technique: Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root). METHODS: Of the 600 patients operated on with the CAVIAAR technique, 60 consecutive patients from a single team underwent double independent reading of the echocardiographic analysis performed in the operative period and yearly after discharge until a maximum of 5-year follow-up. Forty-four patients had preoperative aortic insufficiency (AI) ≥grade 2 (73.3%) and 29 patients (48%) had bicuspid valves. RESULTS: The expansible aortic ring (median size 27 (25-27) mm) significantly reduced the aortic annular base diameter (from 28 (25-29) mm to 23 (21-24) mm) (P < 0.001) without a significant median transvalvular gradient increase (P = 0.545). Cusp repair was performed in 55 patients (91.7%). Operative mortality was 1.7% (1). During the median 19-month (95% confidential interval [11-26]) follow-up, annular diameter and cusp effective height remained stable. There were no valve-related reoperations. One patient died at 6 months postoperatively from congestive heart failure. Freedom from AI ≥grade 2 was 100% at 1-year follow-up and 96.8% ± 3.2% at 3-year follow-up. Systolic root expansibility of the four echocardiographic diameters (aortic annular base, sinuses of Valsalva level, sino tubular junction and tubular aorta) was maintained, throughout the follow-up period with the aortic annular base expansibility coefficient having consistently higher values than the three other levels. CONCLUSIONS: The expansible aortic ring achieved a complete calibrated external annuloplasty and maintained dynamics of the aortic root at mid-term follow-up. Whether this could be a factor for durability of aortic valve repair is currently under evaluation through the CAVIAAR study 10-year follow-up.

Distribution of left ventricular ejection fraction and heart rate values in a cohort of stable coronary patients: the INDYCE registry.

BACKGROUND: The distribution of left ventricular ejection fraction (LVEF) - a key factor in coronary artery disease (CAD) patient management and prognostication - is poorly documented. OBJECTIVE: To determine LVEF and heart rate (HR) values, and describe the management of stable CAD patients in France. METHODS: The INDYCE survey was a prospective, multicentre registry of consecutive stable CAD outpatients attending a cardiology consultation. The survey focused on LVEF values measured using the echocardiographic Simpson biplane method. Drug therapy, resting HR, blood pressure and symptoms were also recorded. RESULTS: Overall, 3119 patients (68.4 +/- 11.0 years; 80% men) were enrolled. LVEF was 56.1+/-11.8% on average, and was poor (<40%) and moderately impaired (40-50%) in 9.6% (n=298) and 19.8% (n=619) of cases, respectively. Symptomatic angina pectoris was present in 19.2% of cases and only 40.6% of patients were asymptomatic (no angina and NYHA class < or = I) despite relatively aggressive management (79.0% of patients had undergone coronary angioplasty and/or bypass graft). Interestingly, 14.1% of patients with LVEF less than 40% were asymptomatic. In multivariable analysis, LVEF less than 40% was associated most strongly with symptomatic status (odds ratio 3.82; 95% CI 2.59-5.63; P<0.0001), together with female sex, age greater than 75 years, diabetes, HR greater or equal to 70 bpm, sedentariness, obesity and disease duration. CONCLUSION: Only 9.6% of stable CAD patients had severe left ventricular dysfunction; among them, 14.1% were strictly asymptomatic. This could justify regular LVEF measurement in CAD patients. Three potentially reversible factors (HR>or=70 bpm, being overweight and sedentariness) were linked independently to the presence of symptoms.

Mitral valvar anomalies and discrete subaortic stenosis.

On the basis of our clinical experience, we hypothesized that the role of mitral valvar anomalies in the development and recurrence of discrete subaortic stenosis might be underestimated. From January 1994 to October 2000, the anatomy of the mitral valve and its relationship to the other components of the left ventricular outflow tract were studied by echocardiography in a series of 73 consecutive patients referred to our institution for surgical correction of discrete subaortic stenosis. In all patients for whom it was considered advisable, surgical correction of the mitral anomaly was performed, together with resection of the fibro-muscular subaortic stenosis. One or more mitral valvar anomalies were found in 35 patients (48%). They could be grouped into five categories: insertion of a papillary muscle into the aortic leaflet, insertion of a papillary muscle into the ventricular wall, "muscularization" of the subaortic portion of the aortic leaflet, anomalous insertion of the valvar tissue into the ventricular wall, and accessory valvar tissue. In all cases with anomalous mitral valvar anatomy, surgical correction was feasible. It consisted of transection of the anomalous papillary muscle or its attachment, resection of accessory valvar tissue, and/or patch enlargement of the aortic leaflet. The incidence of mitral valvar anomalies associated with subaortic stenosis is probably underestimated. Our data suggest that they should be systematically searched for during the evaluation of all cases of subaortic stenosis. Their surgical correction is generally feasible, and might improve the mid and long term results.