Valvular heart disease (VHD) is the next epidemic in the cardiovascular field, affecting millions... more Valvular heart disease (VHD) is the next epidemic in the cardiovascular field, affecting millions of people worldwide and having a major impact on health care systems. With aging of the population, the incidence and prevalence of VHD will continue to increase. However, VHD has not received the attention it deserves from both the public and policymakers. Despite important advances in the pathophysiology, natural history, management, and treatment of VHD including the development of transcatheter therapies, VHD remains underdiagnosed, identified late, and often undertreated with inequality in access to care and treatment options, and there is no medication that can prevent disease progression. The present review article discusses these gaps in the management of VHD and potential actions to undertake to improve the outcome of patients with VHD.
Journal of the American Heart Association, Aug 4, 2020
Background Although US recent data suggest that mitral regurgitation (MR) is severely undertreate... more Background Although US recent data suggest that mitral regurgitation (MR) is severely undertreated and carries a poor outcome, population‐based views on outcome and management are limited. We aimed to define the current treatment standards, clinical outcomes, and costs related to MR at the nationwide level. Methods and Results In total, 107 412 patients with MR were admitted in France in 2014 to 2015. Within 1 year, 8% were operated and 92% were conservatively managed and constituted our study population (68% primary MR and 32% secondary MR). The mean age was 77±15 years; most patients presented with comorbidities. In‐hospital and 1‐year mortality rates were 4.1% and 14.3%, respectively. Readmissions were common (63% at least once and 37% readmitted ≥2 times). Rates of 1‐year mortality or all‐cause readmission and 1‐year mortality or heart failure readmission were 67% and 34%, respectively, and increased with age, Charlson index, heart failure at admission, and secondary MR etiology; however, the event rate remained notably high in the primary MR subset (64% and 28%, respectively). The mean costs of hospital admissions and of readmissions were 5345±6432 and 10 080±10 847 euros, respectively. Conclusions At the nationwide level, MR was a common reason for admission and affected an elderly population with frequent comorbidities. Less than 10% of patients underwent a valve intervention. All subsets of patients who were conservatively managed incurred high mortality and readmissions rates, and MR represented a major societal burden with an extrapolated annual cost of 350 to 550 million euros (390–615 million US dollars). New strategies to improve the management and outcomes of patients with both primary and secondary MR are critical and warranted.
Journal of The American Society of Echocardiography, Sep 1, 2004
We evaluated the diagnostic use of a real-time 3-dimensional (3D) echocardiographic system in 106... more We evaluated the diagnostic use of a real-time 3-dimensional (3D) echocardiographic system in 106 patients referred for echocardiography during a 4-month period. Real-time 3D echocardiography was performed and recorded in parallel with a routine, comprehensive 2-dimensional (2D) study. The diagnoses were exclusively on the basis of 2D findings. The 3D volumes were sliced offline in the 3 dimensions to selectively display specific cardiac structures and reviewed independent of the 2D findings. The 3D studies were graded as: A, new finding not on 2D studies; B, useful anatomic perspective; C, equivalent to 2D studies; or D, missed 2D findings. Compared with 2D echocardiography, 3D echocardiography was graded A in 7 (7%), B in 19 (18%), C in 65 (61%), and D in 15 (14%) cases. In the 26 grade-A and grade-B studies, mitral valve disease and congenital heart disease accounted for 16 (61%) cases. Suboptimal image quality was present in 7 (47%) of the 15 grade-D studies. Thus, real-time 3D echocardiography yields anatomic information comparable with conventional 2D echocardiography in the majority of patients. It can provide new and useful anatomic insight, particularly in patients with mitral valve disease and congenital heart disease. Suboptimal image quality remains a problem for real-time 3D echocardiography in some patients.
BACKGROUND Growing evidence shows a major outcome impact and under-treatment of tricuspid regurgi... more BACKGROUND Growing evidence shows a major outcome impact and under-treatment of tricuspid regurgitation (TR) but large and comprehensive contemporary reports of management and outcome at the nationwide level are lacking. METHODS We gathered all consecutive patients admitted with a diagnosis of likely functional TR in 2014-2015 in France from the "Programme de Médicalisation des Systèmes d'Information" (PMSI) national database and collected rate of surgery, in-hospital mortality, one-year mortality or heart failure (HF) readmission rates. RESULTS In 2014-2015, 17,676 consecutive patients (75±14 years, 51% female) were admitted with a TR diagnosis. Charlson index was ≥2 in 56% of the population and 46% presented with heart failure. TR was associated with prior cardiac surgery, ischemic/dilated cardiomyopathy or mitral regurgitation in 73% of patients. Only 10% of TR patients overall and 67% of those undergoing a mitral valve surgery received a tricuspid valve intervention. Among the 13,654(77%) conservatively managed patients, in-hospital mortality, one-year mortality and one-year mortality or HF readmission rates were 5.1%,17.8% and 41% respectively overall and 5.3%,17.2% and 37% respectively in those no underlying medical conditions (8-times higher than predicted for age and gender). CONCLUSION This nationwide cohort of patients admitted with TR included elderly patients with frequent comorbidities/underlying cardiac diseases. In patients conservatively managed, mortality and morbidity were considerably high over a short time-span. Despite this poor prognosis only 10% of patients underwent a tricuspid valve intervention. These nationwide data showing a considerable risk and potential underuse of treatment highlight the critical need to develop strategies to improve the management and outcomes of TR patients.
Aims Transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve rep... more Aims Transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) has profoundly changed the management of patients with aortic valve stenosis (AS). Large unbiased nationwide data regarding TAVR implementation, impact on SAVR and their respective outcomes are scarce. Methods and results Based on a French administrative hospital-discharge database, we collected data on all consecutive aortic valve replacements (AVRs) performed in France for AS between 2007 and 2019 [106 253 isolated SAVR (49%), 46 514 combined SAVR (21%), and 65 651 TAVR (30%)]. The number of AVR linearly increased between 2007 and 2019 (from 10 892 to 23 109, P for trend < 0.0001) due to a marked increase in TAVR (from 253 to 13 030, P for trend < 0.0001), while SAVR increased up to 2013 and then declined (10 892 in 2007, 12 699 in 2013, and 10 079 in 2019). The Charlson index decreased linearly for TAVR, but in two steps for SAVR (2011 and 2017). In-hospital mortality rates of both SAVR and TAVR declined (both P for trend < 0.0001) and were similar or lower for TAVR than for isolated SAVR in patients 75 years or above in the last 3 years (2017–19). Complication rates of TAVR also declined but permanent pacemaker rates remained high and length of stay substantial (16.7% and median 6 days, respectively, in 2017–19). Conclusion The number of AVR has doubled in a decade and TAVR has become the dominant form of AVR in 2018. The improvement in patient profiles seems to have anticipated the demonstrated benefit of TAVR in intermediate and low-risk patients. In patients 75 years or older, TAVR should be considered as the first option. We also highlight two important areas for improvement, the high permanent pacemaker rates, and the long length of stay even in the contemporary era. Our results may have major implications for clinical practice and policymakers.
Introduction: Reduced left ventricular (LV) myocardial efficiency (myocardial work per O2 (MVO2))... more Introduction: Reduced left ventricular (LV) myocardial efficiency (myocardial work per O2 (MVO2)) and increased sympathetic nervous (SN) activity have been associated with the failing LV. Less is known regarding the right heart. We hypothesized that patients (pts) with RV dysfunction demonstrate increased MVO2 suggesting altered RV energetics and increased SN activity which relate to patient outcomes. Methods: 31 pts with LV systolic dysfunction and NYHA class II or III previously studied to measure LV parameters, were assessed for RV function and size using echocardiography. PET imaging was used to measure RV oxidative metabolism (11C-acetate clearance rate (kmono)) and SN function (11C-Hydroxyephedrine (HED) standard uptake values (SUVs) where decreased HED indicates increased SN activity). MVO2 was extrapolated from the linear relationship of MVO2 to kmono for the LV. Time to first cardiac event (FCE) (hospitalization for heart failure, worsening functional class, arrhythmia, heart transplantation and ...
Introduction: Aortic valve regurgitation (AR) is due to leaflet disease and/or dilatation of the ... more Introduction: Aortic valve regurgitation (AR) is due to leaflet disease and/or dilatation of the functional aortic annulus complex. Understanding the mechanism(s) of AR informs surgical planning of valve and aorta repair. In this study we aimed to examine the etiologies, mechanisms, and outcomes of isolated pure native severe AR in a contemporary consecutive cohort of patients. Methods: From our institutional echocardiography database, we identified all patients with native moderate-to-severe (3+) or severe (4+) AR between 2014-2019. Patients with infective endocarditis, aortic dissection, or other concomitant valve disease were excluded. AR was classified using the El-Khoury classification: Type I-normal leaflet motion (Ia = ascending aorta and sinotubular junction dilatation, Ib = aortic root dilation, Ic = aortic annular dilation), Type II-leaflet prolapse, and Type III-leaflet restriction. Valve anatomy and clinical outcomes were also extracted. Results: A total of 560 patients ...
Valvular heart disease (VHD) is the next epidemic in the cardiovascular field, affecting millions... more Valvular heart disease (VHD) is the next epidemic in the cardiovascular field, affecting millions of people worldwide and having a major impact on health care systems. With aging of the population, the incidence and prevalence of VHD will continue to increase. However, VHD has not received the attention it deserves from both the public and policymakers. Despite important advances in the pathophysiology, natural history, management, and treatment of VHD including the development of transcatheter therapies, VHD remains underdiagnosed, identified late, and often undertreated with inequality in access to care and treatment options, and there is no medication that can prevent disease progression. The present review article discusses these gaps in the management of VHD and potential actions to undertake to improve the outcome of patients with VHD.
Journal of the American Heart Association, Aug 4, 2020
Background Although US recent data suggest that mitral regurgitation (MR) is severely undertreate... more Background Although US recent data suggest that mitral regurgitation (MR) is severely undertreated and carries a poor outcome, population‐based views on outcome and management are limited. We aimed to define the current treatment standards, clinical outcomes, and costs related to MR at the nationwide level. Methods and Results In total, 107 412 patients with MR were admitted in France in 2014 to 2015. Within 1 year, 8% were operated and 92% were conservatively managed and constituted our study population (68% primary MR and 32% secondary MR). The mean age was 77±15 years; most patients presented with comorbidities. In‐hospital and 1‐year mortality rates were 4.1% and 14.3%, respectively. Readmissions were common (63% at least once and 37% readmitted ≥2 times). Rates of 1‐year mortality or all‐cause readmission and 1‐year mortality or heart failure readmission were 67% and 34%, respectively, and increased with age, Charlson index, heart failure at admission, and secondary MR etiology; however, the event rate remained notably high in the primary MR subset (64% and 28%, respectively). The mean costs of hospital admissions and of readmissions were 5345±6432 and 10 080±10 847 euros, respectively. Conclusions At the nationwide level, MR was a common reason for admission and affected an elderly population with frequent comorbidities. Less than 10% of patients underwent a valve intervention. All subsets of patients who were conservatively managed incurred high mortality and readmissions rates, and MR represented a major societal burden with an extrapolated annual cost of 350 to 550 million euros (390–615 million US dollars). New strategies to improve the management and outcomes of patients with both primary and secondary MR are critical and warranted.
Journal of The American Society of Echocardiography, Sep 1, 2004
We evaluated the diagnostic use of a real-time 3-dimensional (3D) echocardiographic system in 106... more We evaluated the diagnostic use of a real-time 3-dimensional (3D) echocardiographic system in 106 patients referred for echocardiography during a 4-month period. Real-time 3D echocardiography was performed and recorded in parallel with a routine, comprehensive 2-dimensional (2D) study. The diagnoses were exclusively on the basis of 2D findings. The 3D volumes were sliced offline in the 3 dimensions to selectively display specific cardiac structures and reviewed independent of the 2D findings. The 3D studies were graded as: A, new finding not on 2D studies; B, useful anatomic perspective; C, equivalent to 2D studies; or D, missed 2D findings. Compared with 2D echocardiography, 3D echocardiography was graded A in 7 (7%), B in 19 (18%), C in 65 (61%), and D in 15 (14%) cases. In the 26 grade-A and grade-B studies, mitral valve disease and congenital heart disease accounted for 16 (61%) cases. Suboptimal image quality was present in 7 (47%) of the 15 grade-D studies. Thus, real-time 3D echocardiography yields anatomic information comparable with conventional 2D echocardiography in the majority of patients. It can provide new and useful anatomic insight, particularly in patients with mitral valve disease and congenital heart disease. Suboptimal image quality remains a problem for real-time 3D echocardiography in some patients.
BACKGROUND Growing evidence shows a major outcome impact and under-treatment of tricuspid regurgi... more BACKGROUND Growing evidence shows a major outcome impact and under-treatment of tricuspid regurgitation (TR) but large and comprehensive contemporary reports of management and outcome at the nationwide level are lacking. METHODS We gathered all consecutive patients admitted with a diagnosis of likely functional TR in 2014-2015 in France from the "Programme de Médicalisation des Systèmes d'Information" (PMSI) national database and collected rate of surgery, in-hospital mortality, one-year mortality or heart failure (HF) readmission rates. RESULTS In 2014-2015, 17,676 consecutive patients (75±14 years, 51% female) were admitted with a TR diagnosis. Charlson index was ≥2 in 56% of the population and 46% presented with heart failure. TR was associated with prior cardiac surgery, ischemic/dilated cardiomyopathy or mitral regurgitation in 73% of patients. Only 10% of TR patients overall and 67% of those undergoing a mitral valve surgery received a tricuspid valve intervention. Among the 13,654(77%) conservatively managed patients, in-hospital mortality, one-year mortality and one-year mortality or HF readmission rates were 5.1%,17.8% and 41% respectively overall and 5.3%,17.2% and 37% respectively in those no underlying medical conditions (8-times higher than predicted for age and gender). CONCLUSION This nationwide cohort of patients admitted with TR included elderly patients with frequent comorbidities/underlying cardiac diseases. In patients conservatively managed, mortality and morbidity were considerably high over a short time-span. Despite this poor prognosis only 10% of patients underwent a tricuspid valve intervention. These nationwide data showing a considerable risk and potential underuse of treatment highlight the critical need to develop strategies to improve the management and outcomes of TR patients.
Aims Transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve rep... more Aims Transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) has profoundly changed the management of patients with aortic valve stenosis (AS). Large unbiased nationwide data regarding TAVR implementation, impact on SAVR and their respective outcomes are scarce. Methods and results Based on a French administrative hospital-discharge database, we collected data on all consecutive aortic valve replacements (AVRs) performed in France for AS between 2007 and 2019 [106 253 isolated SAVR (49%), 46 514 combined SAVR (21%), and 65 651 TAVR (30%)]. The number of AVR linearly increased between 2007 and 2019 (from 10 892 to 23 109, P for trend < 0.0001) due to a marked increase in TAVR (from 253 to 13 030, P for trend < 0.0001), while SAVR increased up to 2013 and then declined (10 892 in 2007, 12 699 in 2013, and 10 079 in 2019). The Charlson index decreased linearly for TAVR, but in two steps for SAVR (2011 and 2017). In-hospital mortality rates of both SAVR and TAVR declined (both P for trend < 0.0001) and were similar or lower for TAVR than for isolated SAVR in patients 75 years or above in the last 3 years (2017–19). Complication rates of TAVR also declined but permanent pacemaker rates remained high and length of stay substantial (16.7% and median 6 days, respectively, in 2017–19). Conclusion The number of AVR has doubled in a decade and TAVR has become the dominant form of AVR in 2018. The improvement in patient profiles seems to have anticipated the demonstrated benefit of TAVR in intermediate and low-risk patients. In patients 75 years or older, TAVR should be considered as the first option. We also highlight two important areas for improvement, the high permanent pacemaker rates, and the long length of stay even in the contemporary era. Our results may have major implications for clinical practice and policymakers.
Introduction: Reduced left ventricular (LV) myocardial efficiency (myocardial work per O2 (MVO2))... more Introduction: Reduced left ventricular (LV) myocardial efficiency (myocardial work per O2 (MVO2)) and increased sympathetic nervous (SN) activity have been associated with the failing LV. Less is known regarding the right heart. We hypothesized that patients (pts) with RV dysfunction demonstrate increased MVO2 suggesting altered RV energetics and increased SN activity which relate to patient outcomes. Methods: 31 pts with LV systolic dysfunction and NYHA class II or III previously studied to measure LV parameters, were assessed for RV function and size using echocardiography. PET imaging was used to measure RV oxidative metabolism (11C-acetate clearance rate (kmono)) and SN function (11C-Hydroxyephedrine (HED) standard uptake values (SUVs) where decreased HED indicates increased SN activity). MVO2 was extrapolated from the linear relationship of MVO2 to kmono for the LV. Time to first cardiac event (FCE) (hospitalization for heart failure, worsening functional class, arrhythmia, heart transplantation and ...
Introduction: Aortic valve regurgitation (AR) is due to leaflet disease and/or dilatation of the ... more Introduction: Aortic valve regurgitation (AR) is due to leaflet disease and/or dilatation of the functional aortic annulus complex. Understanding the mechanism(s) of AR informs surgical planning of valve and aorta repair. In this study we aimed to examine the etiologies, mechanisms, and outcomes of isolated pure native severe AR in a contemporary consecutive cohort of patients. Methods: From our institutional echocardiography database, we identified all patients with native moderate-to-severe (3+) or severe (4+) AR between 2014-2019. Patients with infective endocarditis, aortic dissection, or other concomitant valve disease were excluded. AR was classified using the El-Khoury classification: Type I-normal leaflet motion (Ia = ascending aorta and sinotubular junction dilatation, Ib = aortic root dilation, Ic = aortic annular dilation), Type II-leaflet prolapse, and Type III-leaflet restriction. Valve anatomy and clinical outcomes were also extracted. Results: A total of 560 patients ...
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