Cardiac rotation and relaxation in patients with aortic valve stenosis.

BACKGROUND: Diastolic dysfunction with delayed relaxation and abnormal passive elastic properties has been described in patients with severe pressure overload hypertrophy. The purpose of this study was to evaluate the time course of rotational motion of the left ventricle in patients with aortic valve stenosis using myocardial tagging. METHODS: Myocardial tagging is a non-invasive method based on magnetic resonance which makes it possible to label ('tag') specific myocardial regions. From the motion of the tag's cardiac rotation, radial displacement and translational motion can be determined. In 12 controls and 13 patients with severe aortic valve stenosis systolic and diastolic wall motion was assessed in an apical and basal short axis plane. RESULTS: The normal left ventricle performs a systolic wringing motion around the ventricular long axis with clockwise rotation at the base (-4.4+/-1.6 degrees) and counter-clockwise rotation at the apex (+6.8+/-2.5 degrees) when viewed from the apex. During early diastole an untwisting motion can be observed which precedes diastolic filling. In patients with aortic valve stenosis systolic rotation is reduced at the base (-2.4+/-2.0 degrees; P<0.01) but increased at the apex (+12.0+/-6.0 degrees; P<0.05). Diastolic untwisting is delayed and prolonged with a decrease in normalized rotation velocity (-6.9+/-1.1 s(-1)) when compared to controls (-10.7+/-2.2 s(-1); P<0.001). Maximal systolic torsion is 8.0+/-2.1 degrees in controls and 14.1+/-6.4 degrees (P<0.01) in patients with aortic valve stenosis. CONCLUSIONS: Left ventricular pressure overload hypertrophy is associated with a reduction in basal and an increase in apical rotation resulting in increased torsion of the ventricle. Diastolic untwisting is delayed and prolonged. This may explain the occurrence of diastolic dysfunction in patients with severe pressure overload hypertrophy.

Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.

BACKGROUND: Single-center reports have identified retrograde ascending aortic dissection (rAAD) as a potentially lethal complication of thoracic endovascular aortic repair (TEVAR). METHODS AND RESULTS: Between 1995 and 2008, 28 centers participating in the European Registry on Endovascular Aortic Repair Complications reported a total of 63 rAAD cases (incidence, 1.33%; 95% CI, 0.75 to 2.40). Eighty-one percent of patients underwent TEVAR for acute (n=26, 54%) or chronic type B dissection (n=13, 27%). Stent grafts with proximal bare springs were used in majority of patients (83%). Only 7 (15%) patients had intraoperative rAAD, with the remaining occurring during the index hospitalization (n=10, 21%) and during follow-up (n=31, 64%). Presenting symptoms included acute chest pain (n=16, 33%), syncope (n=12, 25%), and sudden death (n=9, 19%) whereas one fourth of patients were asymptomatic (n=12, 25%). Most patients underwent emergency (n=25) or elective (n=5) surgical repair. Outcome was fatal in 20 of 48 patients (42%). Causes of rAAD included the stent graft itself (60%), manipulation of guide wires/sheaths (15%), and progression of underlying aortic disease (15%). CONCLUSIONS: The incidence of rAAD was low (1.33%) in the present analysis with high mortality (42%). Patients undergoing TEVAR for type B dissection appeared to be most prone for the occurrence of rAAD. This complication occurred not only during the index hospitalization but after discharge up to 1050 days after TEVAR. Importantly, the majority of rAAD cases were associated with the use of proximal bare spring stent grafts with direct evidence of stent graft-induced injury at surgery or necropsy in half of the patients.

Bone marrow mesenchymal stem cells stabilize already-formed aortic aneurysms more efficiently than vascular smooth muscle cells in a rat model.

PURPOSE: Abdominal aortic aneurysms (AAAs) expand because of aortic wall destruction. Enrichment in Vascular Smooth Muscle Cells (VSMCs) stabilizes expanding AAAs in rats. Mesenchymal Stem Cells (MSCs) can differentiate into VSMCs. We have tested the hypothesis that bone marrow-derived MSCs (BM-MSCs) stabilizes AAAs in a rat model. MATERIAL AND METHODS: Rat Fischer 344 BM-MSCs were isolated by plastic adhesion and seeded endovascularly in experimental AAAs using xenograft obtained from guinea pig. Culture medium without cells was used as control group. The main criteria was the variation of the aortic diameter at one week and four weeks. We evaluated the impact of cells seeding on inflammatory response by immunohistochemistry combined with RT-PCR on MMP9 and TIMP1 at one week. We evaluated the healing process by immunohistochemistry at 4 weeks. RESULTS: The endovascular seeding of BM-MSCs decreased AAA diameter expansion more powerfully than VSMCs or culture medium infusion (6.5% ± 9.7, 25.5% ± 17.2 and 53.4% ± 14.4; p = .007, respectively). This result was sustained at 4 weeks. BM-MSCs decreased expression of MMP-9 and infiltration by macrophages (4.7 ± 2.3 vs. 14.6 ± 6.4 mm(2) respectively; p = .015), increased Tissue Inhibitor Metallo Proteinase-1 (TIMP-1), compared to culture medium infusion. BM-MSCs induced formation of a neo-aortic tissue rich in SM-alpha active positive cells (22.2 ± 2.7 vs. 115.6 ± 30.4 cells/surface units, p = .007) surrounded by a dense collagen and elastin network covered by luminal endothelial cells. CONCLUSIONS: We have shown in this rat model of AAA that BM-MSCs exert a specialized function in arterial regeneration that transcends that of mature mesenchymal cells. Our observation identifies a population of cells easy to isolate and to expand for therapeutic interventions based on catheter-driven cell therapy.

Effects of gastric bypass and gastric banding on glucose kinetics and gut hormone release

Rapport de Synthèse : Introduction : outre son effet bénéfique sur le poids, la chirurgie bariatrique améliore de façon considérable l'homéostasie glucide chez les patients diabétiques. Cette amélioration survient très tôt dans la période post-opératoire, avant que le poids ne soit réduit de manière importante. De plus, les interventions chirurgicales qui "court-circuitent" une partie de l'intestin grêle, telle que le by-pass gastrique, apparaissent être plus efficaces que les interventions purement restrictives, telles que le cerclage gastrique. Objectifs : cette étude a pour but d'étudier la cinétique du glucose et la sécrétion d'hormones gastro-intestinales, consécutive à l'ingestion d'une dose charge de glucose, chez des patients opérés d'un by-pass ou d'un cerclage gastrique. Méthodes : nous avons comparé des groupes de femmes non diabétiques ayant bénéficié d'un by-pass gastrique (BPG, n=8) ou d'un cerclage gastrique (CG, n=6) à un groupe de femmes contrôles d'âge et de poids appariées n'ayant subi aucune intervention bariatrique (C, n=8). L'étude a été réalisée alors que le poids des volontaires était stable, soit entre 9 et 48 mois après le BPG, et 25 à 85 mois après le CG. Nous avons étudié, pendant les 4 heures qui ont suivies l'ingestion d'une dose charge de glucose; la cinétique du glucose ingéré et du glucose total à l'aide d'un glucose radio-activement marqué, ainsi que la cinétique de l'insuline et de différentes hormones gastro-intestinales. Résultats : l'apparition du glucose exogène dans la circulation systémique est plus rapide chez les patients opérés d'un BPG et s'accompagne d'une hyperglycémie postprandiale plus brève. La réponse insulinique est également plus précoce et plus importante que dans les deux autres groupes. S'agissant des hormones gastro-intestinales, on observe dans la période postprandiale une augmentation de PYY et de GLP-1 et une suppression de la grehline significativement plus importante après BPG. Discussion : ces différentes observations suggèrent que le BPG est associé à de profonds changements de la cinétique du glucose et des altérations de la régulation d'hormones gastro-intestinales. Les modifications susmentionnées apparaissant être secondaires aux modifications anatomiques consécutives au BPG, i.e. la mise "hors-circuit" de l'estomac distal et de l'intestin grêle proximal, compte tenu du fait qu'elles ne sont pas observées après CG. Finalement, la stimulation de PYY et de GLP-1 ainsi que la suppression postprandiale plus importante de ghréline est compatible avec la diminution spontanée de la prise alimentaire observée chez les patients opérés d'un BPG.

Laparoscopic Gastric Banding Outcomes Do Not Depend on Device or Technique. Long-Term Results of a Prospective Randomized Study Comparing the Lapband® and the SAGB®.

BACKGROUND: Gastric banding still represents one of the most widely used bariatric procedures. It provides acceptable weight loss in many patients, but has frequent long-term complications. Because different types of bands may lead to different results, we designed a randomized study to compare the Lapband® with the SAGB®. We hereby report on the long-term results. METHODS: Between December 1998 and June 2002, 180 morbidly obese patients were randomized between Lapband® or SAGB®. Weight loss, long-term morbidity, and need for reoperation were evaluated. RESULTS: Long-term weight loss did not differ between the two bands. Patients who maintained their band had an acceptable long-term weight loss of between 50 and 60 % EBMIL. In both groups, about half the patients developed long-term complications, with about 50 % requiring major redo surgery. There was no difference in the overall rates of long-term complications or failures between the two groups, but patients who had a Lapband® were significantly more prone to develop band slippage/pouch dilatation (13.3 versus 0 %, p < 0,001). CONCLUSIONS: Although in the absence of complication, gastric banding leads to acceptable weight loss; the long-term complication and major reoperation rates are very high independently from the type of band used or on the operative technique. Gastric banding leads to relatively poor overall long-term results and therefore should not be considered the procedure of choice for the treatment of morbid obesity. Patients should be informed of the limited overall weight loss and the very high complication rates.

A new self-expanding aortic stent valve with annular fixation: in vitro haemodynamic assessment.

OBJECTIVE: Balloon-expandable stent valves require flow reduction during implantation (rapid pacing). The present study was designed to compare a self-expanding stent valve with annular fixation versus a balloon-expandable stent valve. METHODS: Implantation of a new self-expanding stent valve with annular fixation (Symetis, Lausanne, Switzerland) was assessed versus balloon-expandable stent valve, in a modified Dynatek Dalta pulse duplicator (sealed port access to the ventricle for transapical route simulation), interfaced with a computer for digital readout, carrying a 25 mm porcine aortic valve. The cardiovascular simulator was programmed to mimic an elderly woman with aortic stenosis: 120/85 mmHg aortic pressure, 60 strokes/min (66.5 ml), 35% systole (2.8 l/min). RESULTS: A total of 450 cardiac cycles was analysed. Stepwise expansion of the self-expanding stent valve with annular fixation (balloon-expandable stent valve) resulted in systolic ventricular increase from 120 to 121 mmHg (126 to 830+/-76 mmHg)*, and left ventricular outflow obstruction with mean transvalvular gradient of 11+/-1.5 mmHg (366+/-202 mmHg)*, systolic aortic pressure dropped distal to the valve from 121 to 64.5+/-2 mmHg (123 to 55+/-30 mmHg) N.S., and output collapsed to 1.9+/-0.06 l/min (0.71+/-0.37 l/min* (before complete obstruction)). No valve migration occurred in either group. (*=p<0.05). CONCLUSIONS: Implantation of this new self-expanding stent valve with annular fixation has little impact on haemodynamics and has the potential for working heart implantation in vivo. Flow reduction (rapid pacing) is not necessary.

Changes in Aortic Pulse Wave Velocity in Hypertension Post-Menopausal Women: Comparison Between Calcium Channel Blocker (CCB) Vs Angiotensin Receptor Blocker (ARB) Regimen

Objective: To compare effects of a non-renin-angiotensin system (RAS) blocker, using a CCB, or a RAS blocker, using an ARB regimen on the arterial stiffness reduction in postmenopausal hypertensive women. Methods: In this prospective study, a total of 125 hypertensive women (age: 61.4_6 yrs; 98% Caucasian; BW: 71.9_14 kg; BMI: 27.3_5 kg/m2; SBP/ DBP: 158_11/92_9 mmHg) were randomized between ARB (valsartan 320mg_HCTZ) and CCB (amlodipine 10mg _ HCTZ). The primary outcome was carotid-femoral pulse wave velocity (PWV) changes after 38 weeks of treatment. Results: There were no significant differences in baseline demographic data between the two groups. Both treatments effectively lowered BP at the end of the study with similar (p>0.05) reductions in the valsartan (_22.9/_10.9 mmHg) and amlodipine based (_25.2/_11.7 mmHg) treatment groups. Despite a lower (p<0.05 for DBP) central SBP/DBP in the CCB group (_19.2/_10.3 mmHg) compared to the valsartan group (_15.7/_7.6 mmHg) at week 38, a similar reduction in carotid-femoral PWV (_1.7 vs _1.9 m/sec; p>0.05) was observed between both groups. The numerically larger BP reduction observed in the CCB group was associated with a much higher incidence of peripheral edema (77% vs 14%) than the valsartan group. Conclusion: In summary, BP lowering in postmenopausal women led to a reduction in arterial stiffness assessed by PWV measurement. Both regimens reduced PWV at 38 weeks of treatment to a similar degree, despite differences in BP lowering suggesting that the effect of RAS blockade to influence PWV may partly be independent of BP.

Short-term clinical outcomes among patients undergoing transcatheter aortic valve implantation in Switzerland: the Swiss TAVI registry.

AIMS: To evaluate short-term clinical outcomes following transcatheter aortic valve implantation (TAVI) using CE-mark approved devices in Switzerland. METHODS AND RESULTS: The Swiss TAVI registry is a national, prospective, multicentre, monitored cohort study evaluating clinical outcomes in consecutive patients undergoing TAVI at cardiovascular centres in Switzerland. From February 2011 to March 2013, a total of 697 patients underwent TAVI for native aortic valve stenosis (98.1%), degenerative aortic bioprosthesis (1.6%) or severe aortic regurgitation (0.3%). Patients were elderly (82.4±6 years), 52% were females, and the majority highly symptomatic (73.1% NYHA III/IV). Patients with severe aortic stenosis (mean gradient 44.8±17 mmHg, aortic valve area 0.7±0.3 cm²) were either deemed inoperable or at high risk for conventional surgery (STS 8.2%±7). The transfemoral access was the most frequently used (79.1%), followed by transapical (18.1%), direct aortic (1.7%) and subclavian access (1.1%). At 30 days, rates of all-cause mortality, cerebrovascular events and myocardial infarction were 4.8%, 3.3% and 0.4%, respectively. The most frequently observed adverse events were access-related complications (11.8%), permanent pacemaker implantation (20.5%) and bleeding complications (16.6%). The Swiss TAVI registry is registered at ClinicalTrials.gov (NCT01368250). CONCLUSIONS: The Swiss TAVI registry is a national cohort study evaluating consecutive TAVI procedures in Switzerland. This first outcome report provides favourable short-term clinical outcomes in unselected TAVI patients.

Roux-en-y Gastric Bypass is Superior to Gastric Banding in Non-superobese Patients. a Matched-case Study with Five-year Follow-up

Background: Roux-en-Y gastric bypass (RYGBP) and gastric banding (GB) are the two most popular bariatric procedures. Only few studies have compared their results and follow-up duration is usually limited to <3 years. Patients and Methods: Using our prospective bariatric database, we matched non-superobese GB to RYGBP patients for sex, age and BMI to RYGBP. Follow-up considered up to five years. Results: 442 patients were matched in 221 pairs. Mean age (38,6) and mean BMI (43) were identical. Overall operative morbidity was higher after RYGBP (17,2 versus 5,4 %, p<0,001), but major morbidity was similar (3,6 versus 2,2 %, p=0,57). More patients developed long-term complications after GB (43,9 % versus 19 %, p<0,001), and more required reoperations (24,4 % versus 12 %, p=0,001). After RYGBP, reoperations were mainly due to internal hernias (87 %), with no reversal, whereas 18,5 % of the GB patients required band removal. Even including only patients who retained their band, weight loss after RYGBP was better throughout the study period, with 5-year EBMIL of 77,6 % and 61,7 % (p<0,001) after RYGBP and GB respectively. RYGBP was associated with better food tolerance and greater improvement of the lipid profile. Conclusions: GB is associated with a smaller overall operative morbidity and similar major morbidity, but with more long-term complications, more reoperations, a significant number of reversal or conversion procedures, and reduced weight loss when compared with RYGBP. Five-year results of RYGBP are superior to GB and patients should be informed accordingly.

Aortic remodelling in Fabry disease

Aims To evaluate thoracic aortic dilation in patients with Fabry disease (FD). Methods and results A cohort of 106 patients with FD (52 males; 54 females) from three European centres were studied. The diameter of the thoracic aorta was assessed at three levels (sinus of Valsalva, ascending aorta, and descending aorta) using echocardiograms and cardiovascular magnetic resonance imaging. Aortic dilation at the sinus of Valsalva was found in 32.7% of males and 5.6% of females; aneurysms were present in 9.6% of males and 1.9% of females. No aortic dilation was observed in the descending aorta. There was no correlation between aortic diameter at the sinus of Valsalva and cardiovascular risk factors. Conclusion Fabry disease should be considered as a cardiovascular disease that affects the heart and arterial vasculature, including the thoracic aorta. Thus, patients with FD should be closely monitored for the presence, and possible progression and complications of aortic dilation. Clinical Trial Registration: Protocol 101/01. Ethics committee, Faculty of Medicine, Lausanne.

Drawback of aortoplasty for aneurysm of the ascending aorta associated with aortic valve disease.

BACKGROUND: Aortoplasty has been advocated for moderate dilatation of the ascending aorta associated with aortic valve disease. We report our results with this conservative approach. METHODS: Seventeen consecutive patients with unsupported aortoplasty were reviewed. Twelve patients had aortic valve regurgitation and 5 had stenosis. The aortic wall was analyzed histologically in 14 patients. Follow-up was complete, with a mean time of 6 years (range, 2.3 to 10.5 years). RESULTS: Two patients among the 15 hospital survivors died during follow-up of causes unrelated to aortic pathology. Survival at 7 years was 86.7% (+/- 8.8%). Recurring aortic aneurysms developed in 4 patients after a mean time of 63 months, with an event-free survival at 7 years of 41% (+/- 21%). All of these 4 patients had aortic valve regurgitation and cystic medial necrosis. CONCLUSIONS: The recurrence rate of aneurysms after unsupported aortoplasty and aortic valve replacement is high in patients with aortic regurgitation. This strongly suggests that in these patients, the aortic dilatation is related to an underlying wall deficiency, associated with the aortic valve pathology, rather than to the hemodynamic stress imposed by the aortic valve disease.

Aortic root rupture: implications of catheter-guided aortic valve replacement.

PURPOSE OF REVIEW: The safety and efficiency of trans catheter aortic valve implantation (TAVI) has been clearly demonstrated. In high-risk patients, the number of procedures is constantly increasing and in western European countries this procedure is employed in more than 30% of isolated aortic valve replacements. The literature, however, focusing on perioperative aortic root (AoR) rupture is rather limited to just a few reports. The aim of this review is to analyze the pathophysiology of AoR rupture during TAVI, stressing the implications of the morphology of the AoR for this devastating complication. RECENT FINDINGS: Currently, perioperative AoR rupture ranges between 0.5 and 1.5% during TAVI, with almost 100% mortality. Recently, valve oversizing and balloon dilatation in a calcified and small AoR were considered as the most important predictive factors for this complication. SUMMARY: The most fragile unit of the AoR is its anchoring substrate to the ostium of the left ventricle. This membranous structure is not involved in the degenerative process leading to aortic valve stenosis. Due to the TAVI and/or balloon dilatation of the calcium stationed on the three leaflets and their attachment, a lesion may result on this structure. And, as a consequence, there is rupture of the AoR.

Evaluation gériatrique des patients agés candidats a un remplacement valvulaire aortique percutané [Geriatric assessment in old patients candidate to transcatheter aortic implantation].

Aortic stenosis mostly occurs among old-old patients. Once symptoms appear, prognosis is guarded, with 2-year mortality as high as 50%. Transcatheter Aortic Valve Implantation (TAVI) is a new therapeutic option in patients at very high surgical risk, who are mostly older persons. However, TAVI is associated with some complications, and patient selection remains a challenge. Comprehensive geriatric assessment (CGA) identifies patients with medical and functional problems likely to affect the TAVI post-operative course. Collaboration between cardiologists and geriatricians will likely become a standard approach to enhance the assessment of these frail patients and identify those most likely to benefit from TAVI.