BACKGROUNDTrials of patent foramen ovale (PFO) closure to prevent recurrent stroke have been inconclusive. We investigated whether patients with cryptogenic stroke and echocardiographic features representing risk of stroke would benefit from PFO closure or anticoagulation, as compared with antiplatelet therapy.METHODSIn a multicenter, randomized, open-label trial, we assigned, in a 1:1:1 ratio, patients 16 to 60 years of age who had had a recent stroke attributed to PFO, with an associated atrial septal aneurysm or large interatrial shunt, to transcatheter PFO closure plus long-term antiplatelet therapy (PFO closure group), antiplatelet therapy alone (antiplatelet-only group), or oral anticoagulation (anticoagulation group) (randomization group 1). Patients with contraindications to anticoagulants or to PFO closure were randomly assigned to the alternative noncontraindicated treatment or to antiplatelet therapy (randomization groups 2 and 3). The primary outcome was occurrence of stroke. The comparison of PFO closure plus antiplatelet therapy with antiplatelet therapy alone was performed with combined data from randomization groups 1 and 2, and the comparison of oral anticoagulation with antiplatelet therapy alone was performed with combined data from randomization groups 1 and 3.RESULTSA total of 663 patients underwent randomization and were followed for a mean (+/- SD) of 5.3 +/- 2.0 years. In the analysis of randomization groups 1 and 2, no stroke occurred among the 238 patients in the PFO closure group, whereas stroke occurred in 14 of the 235 patients in the antiplatelet-only group (hazard ratio, 0.03; 95% confidence interval, 0 to 0.26; P<0.001). Procedural complications from PFO closure occurred in 14 patients (5.9%). The rate of atrial fibrillation was higher in the PFO closure group than in the antiplatelet-only group (4.6% vs. 0.9%, P = 0.02). The number of serious adverse events did not differ significantly between the treatment groups (P = 0.56). In the analysis of randomization groups 1 and 3, stroke occurred in 3 of 187 patients assigned to oral anticoagulants and in 7 of 174 patients assigned to antiplatelet therapy alone.CONCLUSIONS Among patients who had had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. PFO closure was associated with an increased risk of atrial fibrillation.

The surgical management of severe tricuspid regurgitation (TR) in patients with right ventricular dysfunction (RVD) is challenging. Surgery should be considered in patients with progressive right ventricular dilatation or deterioration of right ventricular function but the presence of severe RVD represents a contraindication [ 1 Vahanian A. Alfieri O. Andreotti F. Antunes M.J. Barón-Esquivias G. Baumgartner H. et al. Guidelines on the management of valvular heart disease (version 2012). Eur. Heart J. 2012; 33: 2451-2496 Crossref PubMed Scopus (3182) Google Scholar , 2 Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin III, J.P. Guyton R.A. et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 2014; 129: e521-e643 Crossref PubMed Scopus (1176) Google Scholar ]. Veno-arterial extracorporeal membrane oxygenation (ECMO) is an effective short-term mechanical circulatory support that has known an exponential, widespread application in the last decade. Owing to the presence of a systemic venous inflow and arterial outflow, it provides biventricular support. Recently, several reports described an original technique of ECMO application as isolated, temporary right ventricular assist device (tRVAD) in patients operated for the implantation of long-term left ventricular assist device [ 3 De Silva R.J. Soto C. P Spratt Extra corporeal membrane oxygenation as right heart support following left ventricular assist device placement: a new cannulation technique. Heart Lung Circ. 2012; 21: 218-220 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar , 4 Haneya A. Philipp A. Puehler T. Rupprecht L. Kobuch R. Hilker M. et al. Temporary percutaneous right ventricular support using a centrifugal pump in patients with postoperative acute refractory right ventricular failure after left ventricular assist device implantation. Eur. J. Cardiothorac. Surg. 2012; 41: 219-223 Crossref PubMed Scopus (6) Google Scholar , 5 Lenoir M. Quessard A. N'guyen A. Kirsch M. Simplified temporary right ventricular support after implantation of a left ventricular assist device. Heart Surg. Forum. 2013; 16: E152-E154 Crossref PubMed Scopus (7) Google Scholar ].

Background: Left ventricular (LV) remodeling has been shown to be related mainly to myocardial infarction (MI) size. We aimed to analyze the respective predictive value of 3D strain parameters, including area strain and biomarkers for the development of early LV remodeling at 30 days after acute MI. Methods: 34 patients with a first MI underwent 3D echocardiography at 2 and 30 days after reperfusion. LV remodeling was defined as an increase in LV end-diastolic volume (EDV, ml) >15% from baseline values. LV volumes (ml), wall motion score index (WMSI), LV ejection fraction (LVEF, %), area strain (AS, %), global longitudinal (GLS, %), circumferential (GCS, %), and radial (GRS, %) strains were correlated with the relative change in EDV (%) at 30 days. Results: At 30 days, LV remodeling was present in 12 patients (35%). Peak values of Troponin (TN, mcg/L) (68 [43-146] vs. 34 [15-107], p=0.2) and creatine phosphokinase (CPK, U/L) (2312 [1717-4075] vs. 1452 [615-2848], p=0.08) were similar in the remodeling and in the non-remodeling groups. LVEF similarly increased in remodeling (47±10% to 56±8%) and in non remodeling (50±7% to 57±6%) groups (p<0.05). At baseline, both LVEF and WMSI were similar in remodeling vs non remodeling group. Among the 3D strain values, GLS was the only strain parameter to be significantly lower in remodeling group (p<0.03) (table). At one month, changes in LVEDV correlated with baseline values of WMSI (r=0.45, p=0.007), GLS (r=0.48, p<0.004), GCS (r=0.42, p<0.01), GRS (r=-0.39, p=0.02), and AS (r=0.47, p<0.006). At multivariate analysis, GLS was the only parameter predictive of remodeling with a cut-off value of -12% by ROC curve analysis (AUC=0.71[0.53-0.89], CI95%) with a sensitivity of 83% and specificity of 59%. View this table: Conclusions: Among all 3D strain parameters, global longitudinal strain appears to be the most accurate deformation parameter to predict early LV remodeling after acute myocardial infarction

Object. - The French Cardiology Society (SFC) systematically recommends (Class I) transesophageal echocardiography (TEE) after any mitral. valve replacement with a mechanical. prosthesis (MMVR). Taking into account the increasing workload of echocardiography laboratories, our attitude was to propose that only post-operative transthoracic echocardiography (TTE) is performed. The purpose of this study was to evaluate the possible risks of this simplified procedure.Methods. - We performed a precise analysis of one full year of practice of MMVR with exhaustive follow-up for the first 2 years concentrating on thromboembolic complications.Results. - From January to December 2003, 84 MMVRs (46 after rheumatic fever, 22 degenerative disease, 11 infective endocarditis (IE) and 5 ischemia) were conducted in 45 women and 39 men of average age 61 years. Early mortality (< 30 days) concerned 5 patients (5.9%). A control TTE to determine normal prosthetic function was performed 7 2 days after surgery and this revealed 2 cases of nonobstructive thrombosis which were treated medically, 3 cases of paraprosthetic regurgitation, and 1 vegetation due to underlying IE. Actuarial. survival was 90.5% at 1 year and 83.3% at 2 years. After a mean follow-up of 179.3 patient-years, 5 patients were reoperated (5.9%): 1 for IE, 1 for paravalvular regurgitation, 1 for mitral valve insufficiency with haemolysis, and 2 for obstructive prosthetic valve thromboses. In addition there were 2 cases of prosthetic valve thrombosis, 8 ischemic strokes (2 ministrokes, 6 sequelar strokes), and 1 peripheral embolism. The global thromboembolic complication rate was therefore 6.1 per 100 patient-years (n=11). There were 4 hemorrhagic events, i.e. a rate of 2.2 events per 100 patient-years. 63% of the 1193 INR conducted were within the target range (3-4.5), 26% were below 3 and 11% were greater than 4.5. 35% of patients with thromboembotic complications had an INR < 3.Conclusion. - Morbidity and mortality during the first 2 years after MMVR were relatively high but equivalent to the values of comparable series in the literature. These complications would not have been reduced by a more precise screening based on early TEE. Despite the increasingly litigious nature of the doctor-patient relationship, it would probably be excessive to oppose that this guideline was not followed in a dispute; in particular as it is difficult to apply this measure as echocardiography departments are overworked. (C) 2008 Published by Elsevier Masson SAS.

Pulmonary arteriovenous malformations (PAVMs) associated with hereditary hemorrhagic telangiectasia may cause severe cerebral complications that may be prevented by embolization therapy. We retrospectively compared the diagnostic value of noninvasive tests for the screening of treatable (amenable to embolization) PAVMs in a series of 105 patients, using chest computerized tomography (CT) and/or pulmonary angiography as a "gold standard." Patients had assessment of dyspnea, chest radiograph, alveolar-arterial PO2 gradient under 100% oxygen (AaPO(2)), contrast echocardiography, and radionuclide perfusion lung scanning. Contrast echocardiography in the supine position was the most sensitive test (93%). The sensitivity of self-reported dyspnea (59%), chest radiograph alone (70%), measurement Of AaPO(2) by the 100% oxygen method (62%), or radionuclide lung scanning (71%), was not suitable for efficient screening. A 100% sensitivity and negative predictive value could be obtained when combining anteroposterior chest radiograph and contrast echocardiography. Our data support a screening algorithm based on the combined use of contrast echocardiography and anteroposterior chest radiograph, followed by chest CT if either test is positive. An alternative is to screen directly by chest CT. However, this algorithm may obviate the need for chest CT in patients without PAVM, who represent a majority of patients with hereditary hemorrhagic telangiectasia.

Aortic valve sparing operations are now widely accepted for ascending aortic aneurysm surgery. We herein report our experience of the Tirone David procedure in larger indications.From January 1997 to August 2003, 50 Tirone David procedure have been performed on 36 male and 14 female (mean age: 60 +/- 15). Five patients presented a Marfan disease and 4 acute dissections. Grade III or IV aortic insufficiency was frequent (40%). Aortic diameter was not particularly dilated, ranging from 44 to 78 mm (mean: 57 +/- 10 mm). Mean ejection fraction: 57 +/- 10%. Mean left ventricular end diastolic diameter =63 +/- 7 mm. An associated mitral valve repair and I coronary bypass were necessary.Mean cross clamp and bypass times =94 min and 122 +/- 28 min respectively. There was one in-hospital mortality. Secondary mortality affected 2 patients (non-cardiac deaths), for a cumulative follow-up of 946 months. During follow-up continence control was always excellent, only I bicuspid valve had an aortic insufficiency >grade II.Tirone David procedure gave satisfactory results as regards both aortic ectasia and aortic regurgitation control. We consider it feasible even in case of aortic dissection but caution is required when facing bicuspid aortic valves.

Aortic valve sparing operations are now widely accepted for ascending aortic aneurysm surgery. We herein report our experience of the Tirone David procedure in larger indications. From January 1997 to August 2003, 50 Tirone David procedure have been performed on 36 male and 14 female (mean age: 60 +/- 15). Five patients presented a Marfan disease and 4 acute dissections. Grade III or IV aortic insufficiency was frequent (40%). Aortic diameter was not particularly dilated, ranging from 44 to 78 mm (mean: 57 +/- 10 mm). Mean ejection fraction: 57 +/- 10%. Mean left ventricular end diastolic diameter =63 +/- 7 mm. An associated mitral valve repair and 1 coronary bypass were necessary. Mean cross clamp and bypass times =94 min and 122 +/- 28 min respectively. There was one in-hospital mortality. Secondary mortality affected 2 patients (non-cardiac deaths), for a cumulative follow-up of 946 months. During follow-up continence control was always excellent, only 1 bicuspid valve had an aortic insufficiency >grade II. Tirone David procedure gave satisfactory results as regards both aortic ectasia and aortic regurgitation control. We consider it feasible even in case of aortic dissection but caution is required when facing bicuspid aortic valves.

Background: Strain rate imaging (SRI), a recently developed Doppler-derived process, allows quantification of myocardial systolic function. We investigate whether SRI quantifies the contractile reserve during dobutamine stress tests in heart transplant patients (HT), when compared with normal individuals.Methods: An incremental dobutamine test (5 to 40 mug/kg per minute) was performed in 10 HT and 15 control subjects, all of whom displayed normal coronary angiography. Gray-scale and color myocardial Doppler data were acquired in standard B-mode views at baseline, low-dose, peak, and recovery. Longitudinal SR was processed from the myocardial velocities for each segment. The changes in maximal systolic SR were used to quantify myocardial contractile reserve.Results: Dobutamine infusion failed to induce clinical symptoms or electrocardiographic (ECG) changes in either group. Visually determined wall motion score was considered normal in all segments for each stage of the dobutamine stress. Heart rate was augmented similarly in both groups during dobutamine infusion. In controls, systolic SR increased gradually with incremental dobutamine dose and returned to baseline values upon recovery. Conversely, in HT patients, the increase in systolic SR was blunted at peak dobutamine, at which point it was significantly different vs controls.Conclusions: Quantitative assessment of myocardial function using SRI during dobutamine stress revealed an impaired contractile reserve in HT patients with normal coronary angiography. These subtle changes in regional myocardial function could not be identified using visual wall motion scoring. Additional studies are necessary to evaluate whether SR imaging detection of contractile reserve impairment will improve clinical efficiency or event prediction in this population.

The case of a right-to-left shunt-induced hypoxemia with an abnormal return of the inferior vena cava (AIVCR) into the left atrium (LA) is reported in a 30-year-old male with cyanosis and polycythemia. The chest X ray and the lung CT scan was normal. Spirometry was normal but the transfert-CO coefficient (KCO) was lowered. Hypoxemia was observed at rest and worsening during exercise. The alveolo-arterial oxygen tension difference under hyperoxia was increased (56 kPa). Contrast echocardiography (CEch) suggested the presence of an AIVCR with a right-to-left shunt only observed by the inferior route. The inferior vena cava (IVC) angiography and the magnetic resonance imaging demonstrated an AIVCR characterized by a direct drainage of IVC in the left atrium. The good tolerance can be explained by the association of AIVCR with an inter-auricular septal defect resulting in a left-to-right shunt which partially corrected the right-to-left shunt. After surgical treatment, arterial blood gases normalized, KCO remained low and CEch became negative.

Un cas d'hypoxemie, par shunt droit-gauche, secondaire a un retour veineux cave inferieur anormal (RVCIA) est rapporte chez un homme de 30 ans presentant une cyanose et une polyglobulie. La radiographie pulmonaire et le scanner thoracique sont normaux. La spirometrie est normale. Le coefficient de transfert du CO (K CO ) est abaisse, Il existe une hypoxemie de repos qui s'aggrave a l'effort. La difference alveolo-arterielle en pression partielle d'oxygene sous 100 % d'O 2 est elevee (56 kPa). L'echocardiographie est en faveur d'un RVCIA avec une epreuve contrastee negative par voie veineuse brachiale alors qu'elle visualise un shunt droit-gauche par voie veineuse femorale. La cavographie inferieure et l'imagerie par resonance magnetique confirment le RVCIA : la VCI s'abouche directement dans l'OG expliquant le shunt droit-gauche. La bonne tolerance clinique observee resulte d'une communication inter-auriculaire, associee au RVCIA, responsable d'un shunt gauche-droit qui corrige partiellement le shunt droit-gauche. Apres traitement chirurgical les gaz du sang se normalisent ; K CO reste abaisse et l'echocardiographie contrastee par voie inferieure devient negative.