Background Transcatheter aortic valve implantation (TAVI) is increasingly performed, with TAVI-in-TAVI reinterventions becoming more frequent. Coronary access after TAVI-in-TAVI can be severely limited by neoskirt formation. Case Summary A 74-year-old man with extensive comorbidities and prior TAVI-in-TAVI (Evolut and Sapien valves) presented with chest pain and troponin elevation. Angiography showed severe left main artery and left anterior descending artery stenoses, but selective coronary engagement was impossible given complete neoskirt obstruction. Using transcatheter electrosurgery, a Steelcore guidewire insulated in a microcatheter was energized to perforate the neoskirt. Percutaneous coronary intervention with drug-eluting stents was successfully completed, with an excellent final result. Discussion To our knowledge, this is the first report of electrosurgical neoskirt perforation to enable coronary revascularization after TAVI-in-TAVI. Take-Home Messages Electrosurgery can safely perforate a neoskirt, restoring coronary access. This novel strategy may become essential as TAVI-in-TAVI procedures increase.

Aims:Dural ectasia (DE) is a criterion for Marfan syndrome (MFS) diagnosis. However, there is no agreement on its diagnosis. We identified new DE criteria on CT-scan imaging using machine-learning (ML) and aimed to evaluate their performance for MFS and Loeys-Dietz detection. Methods and results:MFS patients with FBN1 pathogenic variant, who underwent a complete CT-scan were included and matched 1:1 with controls. The conventional criteria for DE were assessed, as well as new criteria identified by ML (generalized linear model and random forest), regarding MFS diagnostic performance. The new DE criteria were then evaluated for identification of Loeys-Dietz patients with TGFßR1/2 and SMAD3 pathogenic variants. A user-friendly online interface was finally developed to predict the probability of MFS or Loeys-Dietz diagnosis.Between November 2010 and January 2017, 93 MFS patients and their matched controls were included. Mean age was 39 ± 13 years with 45% of women. Conventional definitions of DE showed poor diagnostic performance for MFS: AUC 0.68 (0.61-0.74).The new DE criteria, based on simple CT-scan measurements (antero-posterior diameter of the spinal canal and scalloping) on vertebrae L1, L2 and S1, achieved AUC 0.84 (0.69-0.94). These criteria outperformed the Ghent-criteria for MFS diagnosis. Moreover, in 46 patients with TGFßR1/2 and 40 with SMAD3 pathogenic variants, the new criteria also achieved good diagnostic performance (AUC 0.83 (0.73-0.90) and 0.80 (0.70-0.88) respectively). Conclusion:New CT-scan DE criteria showed good performance for detecting MFS or Loeys-Dietz syndromes. Given the importance of early diagnosis, these new simple criteria offer a promising screening tool.

Background: In patients with significant tricuspid regurgitation, cardiac magnetic resonance imaging (CMR) is the preferred method for the evaluation of right ventricular function and volumes. However validated thresholds are lacking. Aim: The aim of this study was to evaluate CMR assessment of right ventricular volumes in patients with significant (moderate or severe) tricuspid regurgitation, and to define its association with outcomes. Methods: The PRONOVAL study is a retrospective multicentre study using the clinical data warehouse of Greater Paris University Hospitals (AP-HP). Patients were screened for CMR in the PMSI (Programme de m & eacute;dicalisation des syst & egrave;mes d'information). Hospitalization reports were analysed by natural language processing to include patients with tricuspid regurgitation. Exclusion criteria were left heart valvular disease, heart transplantation and cardiac amyloidosis. Primary outcome was a combined criterion of death or tricuspid surgery. Results: Between September 2017 and September 2021, 151 patients with isolated tricuspid regurgitation were screened. Right ventricular function and volumes were available in 86 (57.0%) CMR reports (the complete CMR group). In the complete CMR group, tricuspid regurgitation was severe in 62 patients (72.1%). Median age was 67.0 years (interquartile range 58.0-75.8). Median right ventricular indexed end-diastolic volume was 98.0 mL/m(2) (interquartile range 66.8-118.5). At 2-year follow-up, six patients (9.2%) had undergone tricuspid valve surgery, and 12 patients (18.5%) had died. Right ventricular indexed end-diastolic volume was associated with death or surgery at 2years, with an area under the receiver operating characteristic curve of 0.76 (95% confidence interval 0.75-0.77) for a threshold of 119mL/m(2). Conclusion: Right ventricular indexed end-diastolic volume >119mL/m(2) was found to be an independent indicator of death or surgery in patients with significant tricuspid regurgitation. (c) 2024 Elsevier Masson SAS. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Immune-related myocarditis may be challenging. We report the case of a 66-year-old man with a history of treated multiple myeloma by using immune checkpoint blockers, referred for angina. Coronary angiography was normal. [ 82 Rb]Rubidium PET/CT found diffuse abnormal stress myocardial blood flow and reserve and the apparition of epicardial calcifications. [ 68 Ga]Ga-DOTATOC PET/CT and CMR revealed chronic calcified myocarditis, which was confirmed by histology. This case emphasizes microvascular dysfunction in chronic active myocarditis as assessed by perfusion PET/CT.

BACKGROUND:A link between simple renal cysts (SRCs) and aortic aneurysms or dissection has been reported in the general population. Marfan syndrome (MFS) is associated with severe aortic disease, but very few data on SRCs exist in this population. OBJECTIVES:The objectives were to evaluate: 1) the prevalence of SRCs in patients with MFS, compared to matched controls; and 2) the association between SRCs and aortic events in patients with MFS. METHODS:Consecutive patients with MFS ascertained by a pathogenic variant in the fibrillin-1 gene who underwent complete computed tomography scans at our institution were included and matched 1:1 for age and sex with controls. RESULTS:Between 2010 and 2016, 131 patients with MFS and 131 controls were included. The mean age was 40 ± 14 years, with 42% women. SRC prevalence was higher in patients with MFS: 41% vs 21% in controls (P < 0.0001). SRC prevalence increased with aortic disease severity: 59% in patients with dissection, 43% in patients with aortic aneurysm surgery, and 19% in patients with MFS but without aortic events, similar to 21% in controls (P < 0.009). In multivariable analysis, SRC presence in patients with MFS was independently associated with aortic dissection (adjusted OR: 2.30 [95% CI: 1.00-5.32]; P = 0.049). CONCLUSIONS:The prevalence of SRCs was significantly higher in patients with MFS compared to matched controls. SRCs were independently associated with aortic dissection in MFS. Prospective studies are needed to further evaluate whether SRCs could represent a marker of aortic disease severity in patients with MFS.

BACKGROUND:Despite a frequently favorable evolution during the initial phase, acute myocarditis (AM) remains associated with heart failure and ventricular arrhythmia. There are no large prospective databases to provide robust results. OBJECTIVES:The aim of this study was to describe baseline characteristics, real-life management, in-hospital outcomes, and determinants of prognosis in a large cohort of patients with AM admitted to cardiology, with a comparison of patients with and without initial severity criteria. METHODS:MyocarditIRM (French National Observatory Tracking Viral Myocarditis: Mortality, Cardiovascular Events, Sequels on [Magnetic Resonance Imaging] MRI) is a multicenter prospective observational study of patients with AM confirmed by cardiac magnetic resonance. Patients initially admitted to the intensive care unit or those who died before cardiac magnetic resonance-confirmed diagnosis were not included. RESULTS:In total, 803 consecutive hospitalized patients were enrolled at 49 participating centers between May 2016 and February 2019. The median age was 31 years (Q1-Q3: 23-41 years), and 82% were men. Chest pain was the most frequent symptom (93%), and 112 patients (14%) had severity criteria upon admission (left ventricular ejection fraction <50%, severe ventricular arrythmia, high-degree atrioventricular block, or cardiogenic shock). ST-segment elevation was observed in 49% of patients. Overall, 64 patients (8%) experienced in-hospital complications, defined as a composite of death; left ventricular ejection fraction ≤40%; sustained ventricular or supraventricular arrythmia; cardiogenic shock; and need for mechanical circulatory support, inotropic drugs, temporary cardiac pacing, pacemaker, or cardiac defibrillator implantation. Patients with severity criteria at admission were 10 times more likely to experience in-hospital complications. CONCLUSIONS:This prospective cohort represents the largest AM database worldwide. Although the recruitment process likely led to a selection of patients with lower risk AM, 8% experienced in-hospital complications, the major prognosis factor being severity criteria upon admission. (French National Observatory Tracking Viral Myocarditis: Mortality, Cardiovascular Events, Sequels on (Magnetic Resonance Imaging) MRI; NCT02717143).

Background: Acute myocarditis usually presents as chest pain with rising troponin and normal coronary arteries. Despite frequent favourable evolution at the acute phase, it is associated with heart failure and ventricular rhythm disorders, and is considered the leading cause of sudden cardiac death in young, apparently healthy, adults. There are no specific recommendations for acute myocarditis diagnosis and management, only expert consensus, given the lack of large databases.Aim: The main objective is to describe the contemporary presentation of acute myocarditis, its management and in-hospital outcomes. Secondary objectives are to investigate survival and event-free survival for up to 10 years of follow-up, the determinants of prognosis, the modalities of treatment and follow-up and the gaps between expert consensus and real-life management.Methods: MyocarditIRM is a prospective multicentre cohort that enrolled 803 consecutive patients with acute myocarditis in 49 participating centres in France between 01 May 2016 and 28 February 2019. The diagnosis of acute myocarditis was acknowledged by cardiac magnetic resonance, using the Lake Louise Criteria. Exclusion criteria were age < 18 years, lack of health coverage, contraindication to cardiac magnetic resonance and refusal to participate. Detailed information was collected prospectively, starting at admission. Cardiac magnetic resonance imaging (diagnosis and follow-up) is analysed centrally by the certified core laboratory IHU ICAN. Ten years of follow-up for each patient is ensured by linking with the French National Health Database, and includes information on death, hospital admissions, major clinical events and drug consumption.Conclusion: This prospective cohort with long-term follow-up represents the largest database on acute myocarditis worldwide, and will improve knowledge about its presentation, management and outcomes.

Background The prevalence and location of coronary artery disease (CAD) in anomalous aortic origin of a coronary artery (AAOCA) remain poorly documented in adults. We sought to assess the presence of CAD in proximal (or ectopic) and distal (or nonectopic) segments of AAOCA. We hypothesized that the representation of CAD may differ among the different courses of AAOCA. Methods The presence of CAD was analyzed on coronary angiography and/or coronary computed tomography angiography in 390 patients (median age 64 years; 73% male) with AAOCA included in the anomalous coronary arteries multicentric registry. Results AAOCA mainly involved circumflex artery (54.4%) and right coronary artery (RCA) (31.3%). All circumflex arteries had a retroaortic course; RCA mostly an interarterial course (98.4%). No CAD was found in the proximal segment of interarterial AAOCA, whereas 43.8% of retroaortic AAOCA, 28% of prepulmonic AAOCA and 20.8% subpulmonic AAOCA had CAD in their proximal segments (P < 0.001). CAD was more prevalent in proximal than in distal segments of retroaortic AAOCA (OR: 3.1, 95% CI: 1.8–5.4, P < 0.001). On multivariate analysis, a retroaortic course was associated with an increased prevalence of CAD in the proximal segment (adjusted OR 3.4, 95% CI: 1.3–10.7, P = 0.022). Conclusion Increased prevalence of CAD was found in the proximal segment of retroaortic AAOCA compared to the proximal segments of other AAOCA, whereas no CAD was observed in the proximal segment of interarterial AAOCA. The mechanisms underlying these differences are not yet clearly identified.

We report a case of a 16-year-old man in cardiogenic shock secondary to On-X mitral prosthesis dysfunction due to leaflet embolization through aortic mechanical prosthesis. He underwent an emergency redo mitral valve replacement and, a few days later, leaflet removal by open aortic surgery with full recovery.

BACKGROUND:There is currently no established recommendation for antithrombotic treatment following transcatheter mitral valve replacement (TMVR). However, based on the analogy with surgical mitral bioprosthesis, vitamin K antagonists (VKAs) are predominantly used. OBJECTIVES:The purpose of this study was to compare bleeding and thrombotic events associated with direct oral anticoagulants (DOACs) or VKAs in a prospective cohort of TMVR patients. METHODS:We enrolled consecutive patients who underwent transseptal TMVR using a SAPIEN family prosthesis at our center between 2011 and 2023. The primary outcome was the occurrence of bleeding. VKAs were administered to patients until October 2019, after which DOACs were prescribed. The median follow-up was 4.7 months (Q1-Q3: 2.6-6.7 months). RESULTS:A total of 156 patients were included. The mean age was 65 ± 18.5 years, and 103 patients (66%) were women. The median EuroSCORE II was 7.48% (Q1-Q3: 3.80%-12.97%). Of the participants, 20.5% received DOACs and 79.5% were treated with VKAs. The primary outcome was observed in 50 (40%) patients in the VKA group and 3 (9%) patients in the DOAC group (adjusted HR: 0.21; 95% CI: 0.06-0.74; P = 0.02). Treatment with DOAC was associated with a shorter length of hospital stay. No significant differences were found in terms of thrombotic events, major vascular complications, stroke, or death. CONCLUSIONS:The use of DOACs after TMVR, compared with VKAs, appears to reduce the risk of bleeding complications and decrease the length of hospital stay for patients, without a significant increase in the risk of thrombotic events.

ObjectiveDespite recent advances in surgical and interventional techniques, knowledge on the management of carcinoid heart disease (CHD) remains limited. In a cohort of patients with liver metastases of midgut neuroendocrine tumours (NETs), we aimed to describe the perioperative management and short-term outcomes of CHD. MethodsFrom January 2003 to June 2022, consecutive patients with liver metastases of midgut NETs and severe CHD (severe valve disease with symptoms and/or right ventricular enlargement) were included at Beaujon and Bichat hospitals. All patients underwent clinical evaluation and echocardiography. ResultsOut of 43 (16%) consecutive patients with severe CHD and liver metastases of midgut NETs, 79% presented with right-sided heart failure. Tricuspid valve replacement was performed in 26 (53%) patients including 19 (73%) cases of combined pulmonary valve replacement. The 30-day postoperative mortality rate was high (19%), and preoperative heart failure was associated with worse survival (p=0.02). Epicardial pacemakers were systematically implanted in operated patients and 25% were permanently paced. A postoperative positive right ventricular remodelling was observed (p<0.001). A greater myofibroblastic infiltration was observed in pulmonary versus tricuspid valves (p<0.001), suggesting that they may have been explanted at an earlier stage of the disease than the tricuspid valve, with therefore potential for evolution. ConclusionsWe observed a high postoperative mortality rate and baseline right-sided heart failure was associated with worse outcome. In surviving patients, a positive right ventricular remodelling was observed. Prospective, multicentre studies are warranted to better define the management strategy and to identify biomarkers associated with outcome in CHD.

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter mitral valve implantation (TMVI) has emerged as an alternative to surgery in high risk patients with failing mitral bioprosthesis (valve-in-valve) or annuloplasties (valve-in-ring). The presence of an elevated mean gradient > 5mmHg after the procedure has been defined as an unsuccessful procedure but the impact and outcomes of an elevated mean gradient after TMVI have not been studied. Materials and methods 103 patients undergoing TMVI from 2010 to 2020 were included. Patients were classified in three groups according to mean gradient after the procedure: Group 1< 5mmHg, Group 2 between 5 and 10mmHg and Group 3 > 10mmHg. Results The median age was 71 (52.5–81.5) years. Indications for TMVI were bioprosthesis failure in 67 patients (65%) and ring annuloplasty failure in 36 patients (35%). 84 (81.6%) patients were in NYHA class III or IV. 42 patients were in group 1, 51 in group 2 and 10 in group 3, without any difference in baseline characteristics or procedural findings. At 30 days, the rates of all-cause mortality (respectively 2,6%, 0% and 0%, p = 0,66), rehospitalization for heart failure (respectively 8,4%, 7,7% and 8,4%, p = 0,89), paravalvular leak (10,3%, 27,7%, 22,2%, p = 0,33), LVOT obstruction (respectively 6,3%, 8,2% and 10%, p = 0,99) or valve thrombosis (respectively 7,7%, 4,3% and 0%) were similar in the three groups. At a median follow up of 2 years, 27 patients have died with a cumulative rate of all-cause mortality at 1 and 2 years of 21.5% and 38.1% respectively. The presence of an elevated mean gradient was not associated with increased risk of mortality (HR=1,11, (95% CI [0,93, 1,31]), p = 0,25) An improvement of NYHA class was observed in the three groups without any difference between the groups. Median systolic pulmonary arterial pressure significantly improved in group 1 (from 53mmHg (30–90) in baseline to 45mmHg (25–60), p = 0.005) and 2 (from 55mmHg (30–112) in baseline to 40mmHg (30–75), p = 0.004)) but not in group 3. Conclusion An elevated mean gradient post-TMVI had no impact on cardiovascular outcomes up to 2 years. Further studies with longer follow up are necessary.

A 69-year-old woman with axial and peripheral spondyloarthritis (diagnosed in 2016) was in remission on anti-tumour necrosis factor therapy (adalimumab 40 mg every other week). She presented to our rheumatology unit with a 3-month history of inflammatory back pain and polyarthralgia associated with morning stiffness lasting more than 1 h.

HomeCirculation: Cardiovascular ImagingAhead of PrintFour-Dimensional Flow Magnetic Resonance Imaging Features of a Platypnea-Orthodeoxia Syndrome Caused by a Patent Foramen Ovale No AccessCase ReportRequest AccessAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialNo AccessCase ReportRequest AccessFour-Dimensional Flow Magnetic Resonance Imaging Features of a Platypnea-Orthodeoxia Syndrome Caused by a Patent Foramen Ovale Samuel Sitbon, Phalla Ou, Caroline Nguyen, Carsten Ehmer, Eric Garbarz, Eric Brochet, Adeline Fuchs, Pierre Aubry and Jeremie Abtan Samuel SitbonSamuel Sitbon https://orcid.org/0000-0003-0639-3557 Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique – Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.). , Phalla OuPhalla Ou Département de Radiologie, Hôpital Bichat, AP-HP (Assistance Publique – Hôpitaux de Paris), Université de Paris, France (P.O., C.E.). , Caroline NguyenCaroline Nguyen Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique – Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.). , Carsten EhmerCarsten Ehmer Département de Radiologie, Hôpital Bichat, AP-HP (Assistance Publique – Hôpitaux de Paris), Université de Paris, France (P.O., C.E.). , Eric GarbarzEric Garbarz Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique – Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.). , Eric BrochetEric Brochet Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique – Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.). , Adeline FuchsAdeline Fuchs Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique – Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.). , Pierre AubryPierre Aubry Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique – Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.). and Jeremie AbtanJeremie Abtan Correspondence to: Jeremie Abtan, MD, PhD, Hôpital Bichat, 46 rue Henri Huchard, 75018 Paris. Email E-mail Address: [email protected] https://orcid.org/0000-0001-8968-6624 Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique – Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.). FACT (French Alliance for Cardiovascular Clinical Trials), an F-CRIN network, Paris, France (J.A.). Originally published24 Apr 2023https://doi.org/10.1161/CIRCIMAGING.122.014722Circulation: Cardiovascular Imaging. 2023;0:e014722FootnotesSupplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.122.014722.Correspondence to: Jeremie Abtan, MD, PhD, Hôpital Bichat, 46 rue Henri Huchard, 75018 Paris. Email jeremie.[email protected]fr Previous Back to top Next FiguresReferencesRelatedDetails Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.122.014722PMID: 37092323 Originally publishedApril 24, 2023 Keywordsforamen ovale, patentplatypnea orthodeoxia syndromemagnetic resonance imagingPDF download Advertisement SubjectsDiagnostic TestingEchocardiography