BACKGROUND:Blood culture-negative infective endocarditis (BCNIE) represents a diagnostic and therapeutic challenge. The main reasons for negative blood cultures are prior antibiotic exposure, fungal infection, or infection with fastidious bacteria. CASE SUMMARY:Here, we describe the case of a 61-year-old patient with recurrent BCNIE initially diagnosed as rheumatoid arthritis but ultimately diagnosed as Whipple's endocarditis. DISCUSSION:Whipple's disease is a rare, chronic, multisystemic infection that may relapse if diagnosis is delayed. Whipple's endocarditis is often misdiagnosed, and its treatment remains empirical. This case shows all the typical features, with misdiagnosis causing a delay in identifying the underlying cause of BCNIE and leading to relapse before the initiation of appropriate treatment. TAKE-HOME MESSAGES:In the presence of BCNIE, Whipple's disease should always be considered as a potential underlying cause. Prolonged antibiotic therapy appears to reduce the risk of relapse, although close clinical monitoring is recommended as relapses have been reported.

Introduction Le foramen ovale perméable (FOP) et les infarctus cérébraux cryptogéniques sont liés. Il existe un bénéfice à fermer le FOP après une sélection précise des patients basée sur les préconisations SFNV-SFC. La sélection s’organise au CHU d’Amiens autour de la RCP FOP. Objectifs Décrire la prise en charge des patients présentés en RCP, les données de sécurité de la fermeture de FOP (FFOP) et les taux d’évènements emboliques (AIT, AVC) sur l’ensemble de la population présentée en RCP, fermée ou non. Méthodes Étude rétro-prospective entre décembre 2017 et mars 2020 des patients présentés en RCP FOP du CHU d’Amiens avec comparaison des caractéristiques des groupes « fermeture » et « traitement médical seul ». Les données suivantes ont été recueillies : modalités de prise en charge diagnostiques et thérapeutiques, évènements emboliques et données de sécurité liée à la fermeture de FOP. Résultats Quatre-vingt-neuf patients ont constitué le groupe « fermeture » et 35 le groupe « traitement médical seul ». Soixante et onze patients ont bénéficié d’une FFOP. Quatre patients du groupe FFOP ont présenté un évènement ischémique cérébral dont 2 dans l’attente de la FFOP (délai moyen de FFOP 5 mois après RCP, suivi moyen 13 mois), 5 ont présenté une complication liée à la procédure dont 1 décès présumé vasculaire à 8 mois de la FFOP. Aucun patient du groupe « traitement médical seul » n’a présenté de récidive embolique (suivi moyen 13,4 mois). Discussion Dans cette étude de pratique, le taux de récidive sur la période d’observation dans le groupe FFOP est supérieur à celui des essais. La moitié des récidives sont survenues dans l’attente de la FFOP avec un nouveau bilan étiologique négatif, confirmant la sélection appropriée des patients. Nous suggérons de raccourcir le délai de FFOP. Le taux d’EIG est identique à celui des essais mais un décès inexpliqué est survenu à 8 mois de la FFOP. Conclusion Les études de pratiques permettent d’analyser et de faire évoluer les prises en charge. En parallèle du raccourcissement des délais du bilan étiologique et de la FFOP, nous proposons dans l’attente un AOD chez les patients à plus haut risque.

Introduction Un foramen ovale perméable (FOP) est déterminé couramment par échocardiographie en utilisant du sérum physiologique agité comme agent de contraste. Il peut être difficile à visualiser d’où l’intérêt d’optimiser sa recherche. Observation Nous rapportons le cas d’une patiente de 30 ans aux antécédents d’HTA gravidique et de pré-éclampsie ayant présentée une aphasie révélant un infarctus sylvien superficiel et profond gauche. Le bilan était en faveur d’un AVC ischémique cryptogénique. L’ETT avec épreuve de contraste réalisée avec du sérum physiologique a montré un FOP avec un passage bref et unique des bulles lors de la manœuvre de Valsalva et l’ETO était négative. Il n’y avait pas d’anévrisme du septum inter-auriculaire. Devant la discordance entre le résultat de l’ETT et de l’ETO, il est décidé en RCP FOP d’optimiser la recherche de FOP par l’utilisation de Gélofusine® (macromolécule de gélatine couramment utilisée comme agent de remplissage en réanimation). L’ETT optimisée avec la Gélofusine® a cette fois montrée un FOP significatif lors de la manœuvre de Valsalva lors de plusieurs boucles (Fig. 1, Fig. 2). La patiente a bénéficié d’une fermeture de FOP. Discussion La Gélofusine® présente des avantages par rapport au SP : meilleur contraste, visible pendant plus de cycles cardiaques et les bulles formées sont plus petites et plus stables. La méthode d’optimisation par la manœuvre de Valsalva augmente la sensibilité de 40 % pour la détection du FOP mais peut être difficile à réaliser, notamment au cours de l’ETO. Par conséquent, l’ETT pourrait être plus fiable pour évaluer le degré de shunt, en particulier au repos pour les patients qui ne parviennent pas à réaliser la manœuvre de Valsalva. Conclusion Visualiser le FOP est déterminante dans le bilan des AVC inexpliqués du sujet jeune pour discuter de sa fermeture. La Gélofusine® pourrait permettre de mettre en évidence plus de FOP. Nous soumettons une étude prospective sur cette question (OptiFOP®).

Introduction: Right-ventricular-to-pulmonary artery (RV-PA) coupling, measured as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP), has emerged as a predictor factor in patients undergoing transcatheter aortic valvular replacement (TAVR). Right ventricular longitudinal shortening fraction (RV-LSF) outperformed TAPSE as a prognostic parameter in several diseases. We aimed to compare the prognostic ability of two RV-PA coupling parameters (TAPSE/PASP and the RV-LSF/PASP ratio) in identifying MACE occurrences. Method: A prospective and single-center study involving 197 patients who underwent TAVR was conducted. MACE (heart failure, myocardial infarction, stroke, and death within six months) constituted the primary outcome. ROC curve analysis determined cutoff values for RV-PA ratios. Multivariable Cox regression analysis explored the association between RV-PA ratios and MACE. Results: Forty-six patients (23%) experienced the primary outcome. No significant difference in ROC curve analysis was found (RV-LSF/PASP with AUC = 0.67, 95%CI = [0.58–0.77] vs. TAPSE/PASP with AUC = 0.62, 95%CI = [0.49–0.69]; p = 0.16). RV-LSF/PASP < 0.30%.mmHg−1 was independently associated with the primary outcome. The 6-month cumulative risk of MACE was 59% (95%CI = [38–74]) for patients with RV-LSF/PASP < 0.30%.mmHg−1 and 17% (95%CI = [12–23]) for those with RV-LSF/PASP ≥ 0.30%.mmHg−1; (p < 0.0001). Conclusions: In a contemporary cohort of patients undergoing TAVR, RV-PA uncoupling defined by an RV-LSF/PASP < 0.30%.mmHg−1 was associated with MACE at 6 months.

Background: The first wave of the coronavirus disease 2019 pandemic significantly changed behaviour in terms of access to healthcare. Aim: To assess the effects of the pandemic and initial lockdown on the incidence of acute coronary syndrome and its long-term prognosis. Methods: Patients admitted for acute coronary syndrome from 17 March to 6 July 2020 and from 17 March to 6 July 2019 were included. The number of admissions for acute coronary syndrome, acute complication rates and 2-year rates of survival free from major adverse cardiovascular events or death from any cause were compared according to the period of hospitalization. Results: In total, 289 patients were included. We observed a 30 +/- 3% drop in acute coronary syndrome admissions during the first lockdown, which did not recover in the 2 months after it was lifted. At 2 years, there were no significant differences in the combined endpoint of major adverse cardiovascular events or death from any cause between the different periods (P = 0.34). Being hospitalized during lockdown was not predictive of adverse events during follow-up (hazard ratio 0.87, 95% confidence interval 0.45-1.66; P = 0.67). Conclusions: We did not observe an increased risk of major cardiovascular events or death at 2 years from initial hospitalization for patients hospitalized during the first lockdown, adopted in March 2020 in response to the coronavirus disease 2019 pandemic, potentially as a result of the lack of power of the study. (c) 2023 Elsevier Masson SAS. All rights reserved.

Background - New-onset atrial fibrillation (NOAF) is a well-known complication of ST-segment elevation myocardial infarction (STEMI), probably due to left atrial (LA) remodelling. LA strain (LAS) can predict NOAF in several cardiovascular diseases. Objective - To assess whether LAS predicts NOAF in sinus rhythm patients with STEMI during hospitalization. Methods - Adults with a STEMI and transthoracic echocardiography performed within 48 hours of admission were included. LAS analysis, performed by automated software, recorded LAS during the reservoir phase (LASr), the conduit phase (LAScd) and the contraction phase (LASct). Results - From May 2021 to November 2022, 175 patients were included, 21 (12%) of whom developed NOAF. NOAF patients were older (median [Q1-Q3]: 67 [59-80] vs 59 [51-67] years; P = 0.006) and had a higher Thrombolysis In Myocardial Infarction scores (4 [2-7] vs 3 [1-4]; P = 0.005). All LAS parameters were significantly impaired in NOAF patients, especially LASr (13.0% [10.5-28.4] vs 36.6% [29.0-44.9]; P = 0.001). An LASr cut-off of 27% had a sensitivity of 81% and a specificity of 80% to identify patients with NOAF. In a multivariable model, LASr was significantly associated with NOAF (odds ratio 1.18, 95% confidence interval 1.09-1.26; P = 0.003). The cumulative risk of NOAF during hospital stay was 30% (18-43 with LASr < 27% and 4% [1.5-8.5] with LASr >= 27% [P < 0.0001]). Conclusion - NOAF is a frequent complication of STEMI. LASr seems helpful for identifying patients at high risk of NOAF during hospitalization. (c) 2024 Les Auteurs. Publie par Elsevier Masson SAS. Cet article est publie en Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

French guideline recently added the presence of an “abnormal left ventricle” on transthoracic echocardiography (TTE) to define very high-risk diabetic patients who may benefit from silent coronary artery disease (CAD) screening. We aimed to investigate the incremental value of resting Global Longitudinal Strain (GLS) in predicting stress TTE positivity in asymptomatic patients with diabetes mellitus (DM). Consecutive asymptomatic patients with DM referred for screening for silent CAD by stress TTE (effort of dobutamine) between January 2017 and December 2018 were included (n = 273). Stress test positivity was defined as stress-induced new or worsening of preexisting left ventricular wall motion abnormalities. Patients with a positive stress test (n = 28; 10%) were more likely to be smokers (71% vs. 17%), to have known diabetes for more than 10 years, carotid atheroma, diabetic nephropathy, diabetic retinopathy (57.1% vs. 18.0%), moderate or severe aortic or mitral calcifications and a lower GLS (−16.7 ± 2.9 vs. −18.9 ± 2.2%) than those with a negative test (all P ≤ 0.014). On multivariate logistic regression analysis, a DM duration > 10 years, diabetic retinopathy and lower GLS (OR [95% CI] = 0.76 [0.64–0.93] per % decrease) remained independently associated with a positive stress TTE. The Chi2 of the model was significantly improved by the addition of GLS on top of the baseline clinical variables, repolarization abnormalities and DM related complications (Chi2 56.9 to 73.8; P < 0.001) (Table 1, Fig. 1). Screening CAD in asymptomatic patients with DM is challenging and debated. In this context, it is crucial to identify early markers of CAD in this population. Our study shows that GLS is strongly associated with the presence of silent ischemia and could be one of these new parameters to be routinely assessed in this population.

BACKGROUND:Screening for silent coronary artery disease in asymptomatic patients with diabetes mellitus (DM) is challenging and controversial. In this context, it seems crucial to identify early markers of coronary artery disease. METHODS:The aim of this study was to investigate the incremental value of resting left ventricular (LV) global longitudinal strain (GLS) for the prediction of positive results on stress (exercise or dobutamine) transthoracic echocardiography in 273 consecutive asymptomatic high-risk patients with DM. Positive results on stress transthoracic echocardiography were defined as stress-induced LV wall motion abnormalities (new or worsening preexisting abnormalities). RESULTS:Compared with patients with negative stress results, those with positive stress results (n = 28 [10%]) more frequently had cardiovascular risk factors, complications of DM, vascular disease, moderate and severe calcification of the aortic valve and mitral annulus, and worse resting LV GLS (-16.7 ± 2.9% vs -19.0 ± 1.9%, P < .001). On multivariable logistic regression analysis, DM duration > 10 years, diabetic retinopathy, LV hypertrophy, and impaired LV GLS (odds ratio, 1.39 [95% CI, 1.14-1.70] per percentage increase; odds ratio, 5.16 [95% CI, 1.96-13.59] for LV GLS worse than -18%) were independently associated with positive results on stress transthoracic echocardiography. The area under the curve to predict positive results was 0.74 for LV GLS with a cutoff of -18.0% (sensitivity 68%, specificity 78%). The area under the curve of the multivariable model to predict test results was improved by the addition of LV GLS (P < .001), with a bias-corrected area under the curve after bootstrapping of 0.842 [95% CI, 0.753-0.893]. CONCLUSIONS:The present findings show that resting LV GLS is associated with the presence of silent ischemia and could be useful to better identify asymptomatic patients with DM who might benefit from coronary artery disease screening.

BACKGROUND:Dilatation of the ascending aorta has an important role in the anatomical conformation of interatrial septum (IAS) especially when a patent foramen ovale (PFO) is present. The aim of the study was to investigate the relationship between ascending aortic dilation and PFO-related cryptogenic stroke in a cohort of cryptogenic strokes.METHODS:It is a retrospective, single-center echocardiographic study assessing aortic root dilatation in 315 consecutive patients with cryptogenic stroke between January 2011 and January 2019. Aortic root dilatation was defined by a diameter of the Valsalva sinuses of the proximal aorta >40 mm. Predictive factors of PFO were assessed by a multivariate analysis. Propensity score matching was applied to account for clinical differences.RESULTS:Of the 315 patients, 68 (22%) had an aortic root dilatation and 167 (53%) had a PFO. In the aortic root dilation group, PFO was more often diagnosed (n = 47/68 [69%], vs n = 120/247 [49%], P = .004). In the PFO group with aortic dilatation, IAS was more mobile (n = 37/47[79%] vs n = 69/120[57%], P < .012) and smaller (2.3 ± 0.5 vs 2.5 ± 0.5 mm, P < .009). On multivariate analysis, aortic root dilatation (OR: 2.6; 95% CI [1.2-5.6]; P = .001) and IAS hypermobility (OR: 5.2 95% CI [2.7-10]; P = .001) were associated with PFO. After propensity matching, aortic root dilatation remained strongly associated with PFO (n = 34/107 [32%] vs 15/107[14%], P = .002).CONCLUSION:Aortic root dilation and IAS hypermobility were strongly associated with PFO-related cryptogenic stroke.

L’insufficienza aortica (IA) cronica resta asintomatica per lungo tempo, mentre le forme acute sono classicamente molto sintomatiche e spesso scarsamente tollerate. Le principali eziologie delle IA croniche nei paesi occidentali sono la malattia annuloectasica, le bicuspidie, le cause farmacologiche e il reumatismo articolare acuto. L’endocardite infettiva è responsabile della maggior parte delle IA acute, mentre la dissecazione aortica e i traumi toracici sono cause più rare. La scoperta di un soffio diastolico al focolaio aortico consente la diagnosi di IA e deve portare alla realizzazione di un’ecocardiografia, che è l’esame chiave nel bilancio dell’IA. Essa permette di confermare la diagnosi, di quantificare la gravità del rigurgito, di specificare il meccanismo e l’eziologia della perdita, di apprezzare l’impatto sul ventricolo sinistro (VS) e sulle pressioni polmonari nonché di valutare il grado di dilatazione dell’aorta ascendente. Il trattamento dell’IA grave si basa sulla chirurgia della valvola aortica, che, il più delle volte, consiste nella sostituzione della valvola aortica (SVA). L’indicazione chirurgica è formale in caso di grave IA sintomatica. Nelle forme croniche gravi asintomatiche, le indicazioni dipendono principalmente dalla ripercussione ventricolare sinistra (diametro e frazione di eiezione [FE]) della perdita aortica e dal grado di dilatazione dell’aorta toracica ascendente.

La insuficiencia aórtica (IAo) crónica permanece asintomática durante largo tiempo, mientras que las formas agudas son clásicamente muy sintomáticas y con frecuencia mal toleradas. Las principales etiologías de las IAo crónicas en los países occidentales son la enfermedad anuloectasiante, las bicúspides, las causas medicamentosas y la fiebre reumática aguda. La endocarditis infecciosa es responsable de la mayoría de las IAo agudas, y son causas más infrecuentes las disecciones aórticas y los traumatismos torácicos. La detección de un soplo diastólico en el foco aórtico permite establecer el diagnóstico de IAo y requiere la realización de una ecocardiografía, que es la prueba de elección en el estudio de la IAo. Permite confirmar el diagnóstico, cuantificar la gravedad del reflujo, precisar el mecanismo y la etiología del reflujo, y valorar la repercusión en el ventrículo izquierdo (VI) y las presiones pulmonares, así como el grado de dilatación de la aorta ascendente. El tratamiento de la IAo grave se basa en la cirugía valvular aórtica que casi siempre consistirá en una sustitución valvular aórtica (SVA). La indicación quirúrgica es clara en caso de IAo grave sintomática. En las formas crónicas graves asintomáticas, las indicaciones dependen fundamentalmente de la repercusión sobre el ventrículo izquierdo (diámetro y fracción de eyección [FE]) del reflujo aórtico y del grado de dilatación de la aorta torácica ascendente.

Background and aims. - We hypothesized that large exercise-induced increases in aortic mean pressure gradient can predict haemodynamic progression during follow-up in asymptomatic patients with aortic stenosis.Methods. - We retrospectively identified patients with asymptomatic moderate or severe aortic stenosis (aortic valve area < 1.5 cm(2) or < 1 cm(2)) and normal ejection fraction, who underwent an exercise stress echocardiography at baseline with a normal exercise test and a resting echocardiography during follow-up. The relationship between exercise-induced increase in aortic mean pressure gradient and annualised changes in resting mean pressure gradient during follow-up was investigated.Results. - Fifty-five patients (mean age 66 15 years; 45% severe aortic stenosis) were included. Aortic mean pressure gradient significantly increased from rest to peak exercise (P < 0.001). During a median follow-up of 1.6 [1.1-3.2] years, resting mean pressure gradient increased from 35 +/- 13 mmHg to 48 16 mmHg, P < 0.0001. Median annualised change in resting mean pressure gradient during follow-up was 5 [2-11] mmHg. Exercise-induced increase in aortic mean pressure gradient did correlate with annualised changes in mean pressure gradient during follow-up (r=0.35, P=0.01). Hemodynamic progression of aortic stenosis was faster in patients with large exercise-induced increase in aortic mean pressure gradient (> 20 mmHg) as compared to those with exercise-induced increase in aortic mean pressure gradient < 20 mmHg (median annualised increase in mean pressure gradient 19 [6-28] vs. 4 [2-10] mmHg/y respectively, P=0.002). Similar results were found in the subgroup of 30 patients with moderate aortic stenosis.Conclusion. - Large exercise-induced increases in aortic mean pressure gradient correlate with haemodynamic progression of stenosis during follow-up in patients with asymptomatic aortic stenosis. Further studies are needed to fully establish the role of ESE in the decision-making process in comparison to other prognostic markers in asymptomatic patients with aortic stenosis. (C) 2017 Elsevier Masson SAS. All rights reserved.

Background—To prevent left ventricular dysfunction (LVD), surgery is recommended in patients with severe primary mitral regurgitation as soon as ejection fraction (EF) ⩽60% or LV end-systolic diameter ≥40 mm. However, LVD may be concealed behind preoperative normal LVEF and LV end-systolic diameter. We sought to identify whether a new composite echocardiographic Doppler marker of the LV ejection according to the LV dilatation may predict postoperative LVD and outcome after mitral valve repair in patients with primary mitral regurgitation. Methods and Results—Between 1991 and 2010, patients who underwent mitral valve repair for primary mitral regurgitation were studied. From preoperative echocardiography, we calculated LV ejection index (LVEI) using following formula: LVEI=indexed LV end-systolic diameter/LV outflow tract time–velocity integral. In the 278 patients included, the best correlation with postoperative LVEF was found with LVEI (r=−0.40; P<0.0001), even in patients with preoperative LVEF≥60% (r=−0.46; P<0.0001). In multivariable analysis, LCEI>1.13 was an independent predictor of postoperative LVD (P<0.0001). During a mean follow-up of 10±4.6 years, 67 (29%) deaths occurred. When compared with patients with preserved LVEI, those with LVEI>1.13 had significantly lower both survival and cardiac death–free survival (P=0.017 and P=0.008, respectively). Similar results were found in patients with preoperative LVEF≥60% (P=0.049 and P=0.016, respectively). In Cox proportional hazard model, after meticulous adjustment for cofactors, LVEI>1.13 remains independently associated with death (hazard ratio, 1.64; P=0.039) and cardiac-related death (hazard ratio, 3.27; P=0.026). Conclusions—After mitral valve repair for primary mitral regurgitation, the preoperative LVEI is a new and simple composite parameter of both LV dilatation and LV forward flow able to accurately predict postoperative LVD and outcome.

OBJECTIVES The aim of this study was to assess the role of the dimensionless index (DI) in a registry of patients with aortic stenosis (AS) to objectively establish prognostic DI thresholds for various degrees of AS severity.BACKGROUND Otis a classic marker of severity in AS that does not rely on the estimation of the left ventricular outflow tract (LVOT) cross-sectional area. Although DI estimation is straightforward, its outcome implications have never been tested in the context of routine clinical practice.METHODS This analysis includes 488 patients with preserved (>= 50%) ejection fraction and no or minimal subjective symptoms, diagnosed with >= mild AS. DI was computed as the ratio of the LVOT time-velocity integral to that of the aortic valve jet, and on the basis of the correlation with peak aortic jet velocity, the population was divided into 3 groups: DI <0.20, DI 0.20 to 0.25, and DI >0.25.RESULTS The 5-year survival free of events (death or need for aortic valve replacement) was 56 +/- 3% for DI >0.25, 41 +/- 6% for DI 0.20 to 0.25, and 22 +/- 5% for DI <0.20 (p for trend <0.001). The risk of events increased linearly with DI <0.25 (adjusted hazard ratio [HR]: 1.14; 95% confidence interval [CI]: 1.05 to 1.29) per 0.05 DI decrement; p = 0.015). On multivariable analysis, compared with patients with DI >0.25, those with DI 0.20 to 0.25 and those with DI <0.20 incurred an excess risk of events (adjusted HR: 1.65; 95% Cl: 1.20 to 2.27 for DI 0.20 to 0.25 vs. DI >0.25, and adjusted HR: 2.62; 95% Cl: 1.90 to 3.63 for DI <0.20 vs. DI >0.25). The association of DI and outcome was consistent in subgroups, with no interaction between DI outcome prediction and LVOT diameter, body surface area, or index stroke volume (all p for interaction >= 0.10)CONCLUSIONS Our results demonstrate that the DI is a simple and reliable marker of AS severity with clear prognostic implications. DI <0.25 is associated with an excess risk of events after diagnosis; therefore, this cutoff should be used for AS severity assessment and for therapeutic decisions. (C) 2015 by the American College of Cardiology Foundation.

Exercise transthoracic echocardiography (ExE) was recently proposed to evaluate tolerance and help risk stratification of mitral regurgitation (MR). Few data are available on the feasibility of Doppler echocardiographic recordings at exercise in daily practice in both secondary and primary MR. Comprehensive resting and ExE were performed in 72 unselected patients (age 59 ± 15 years, 62 % men), with no or minimal symptoms, with at least moderate (mean effective regurgitant orifice area (ERO) = 36 ± 14 mm(2)) primary or secondary MR in two French university hospitals. At rest, quantification of ERO was more challenging in semi-supine position than in classic left lateral decubitus position (55/72; 76 % vs 66/72; 92 %; p = 0.012), particularly in mitral valve (MV) prolapse (35/47; 74 %). During exercise, ERO was only obtained in 30/55 (55 %) patients and was more difficult to assess in MV prolapse than in rheumatic or ischemic MR (respectively in 43, 67 and 88 %, p = 0.046). At peak exercise, ERO was more frequently obtained in symptomatic than asymptomatic patients (77 vs 37 %, p = 0.046) because peak heart rate was lower (113 ± 20 vs 133 ± 23 bpm, p = 0.026). Systolic pulmonary artery pressure (SPAP) was obtained in 69 patients (96 %) at rest and in 60 patients (83 %) at peak exercise (Pex). LV contractile reserve (CR), monitored in all patients (100 %), was found in 51/72 patients (71 %). In daily ExE, monitoring of the CR and SPAP appeared less challenging than MR quantification by the PISA method. Monitoring of ERO was more feasible in ischemic MR than in MV prolapse.

Background. - Risk stratification in asymptomatic patients with severe aortic stenosis (AS) is based on exercise test results. However, differentiating between pathological and physiological breathlessness during exercise is sometimes challenging. Cardiopulmonary exercise testing (CPET) may improve quantification of cardiopulmonary exercise capacity in patients with valve diseases.Aims. - To assess the ability of CPET to detect abnormal responses to exercise and a clinical endpoint (occurrence of European Society of Cardiology guidelines surgical class I triggers).Methods. Forty-three consecutive patients (mean age 69 13 years; 31 men) with no reported symptoms and severe AS (aortic valve surface area < 1 cm2 or indexed aortic valve surface area < 0.6 cm2/ m2) prospectively underwent symptom-limited CPET.Results. Twelve (28%) patients had an abnormal exercise test (AET) with symptoms (abnormal dyspnoea n=11; angina n= 1). Both VE/VCO2 slope > 34 (hazard ratio [HR] = 5.76, 95% confidence interval [CI] 1.086-30.587; P=0.04) and peak VO2 < 14 mL/kg/min (HR 6.01, 95% CI 1.153-31.275; P=0.03) were independently associated with an AET. Furthermore, VE/VCO2 slope >34 (HR 3.681, 95% CI 1.318-10.286; P=0.013) and peak V02 < 14 mL/kg/min (HR 3.058, 95% CI 1.074-8.713; P=0.036) were independent predictors of reaching the clinical endpoint.Conclusions. Cardiopulmonary exercise testing is a useful tool for characterizing breathlessness during an exercise test in apparently asymptomatic patients with AS. Peak V02 <14 mL/kg/min and VE/VCO2 slope> 34 were associated with an AET and the occurrence of European Society of Cardiology guideline surgical class I triggers. (C) 2014 Elsevier Masson SAS. All rights reserved.

a Departement de Cardiologie, Centre Hospitalier Universitaire Timone, Assistance Publique Hopitaux de Marseille, Aix-Marseille Universite, France b URMITE, CNRS-UMR 6236, Faculte de Medecine, Aix-Marseille Universite, France c Service de Chirurgie Cardiaque, Centre Hospitalier Universitaire Timone, Assistance Publique Hopitaux de Marseille, Aix-Marseille Universite, France d Departement de Cardiologie, Centre Hospitalier Universitaire d'Amiens, France e INSERM, ERI 12, Amiens, France f Laboratoire de Microbiologie, Centre Hospitalier Universitaire Timone, Assistance Publique Hopitaux de Marseille, Aix-Marseille Universite, France g Departement de Chirurgie Cardiaque, Centre Hospitalier Universitaire d'Amiens, France h Departement d'Anesthesie, Centre Hospitalier Universitaire d'Amiens, France