This prospective registry reflects the real-life experience of transcatheter aortic valve implantation in high-risk elderly patients in France. The early results are satisfactory in terms of feasibility, short-term haemodynamic and functional improvement, and safety. Longer term follow-up will be further assessed.

In patients with LF/LGAS without CR on DSE, AVR is associated with better outcome compared with medical management. Surgery should not be withheld from this subset of patients solely on the basis of lack of CR on DSE.

Background-Dobutamine stress hemodynamics (DSH) has the potential to stratify operative risk in low-gradient aortic stenosis (AS), but little is known about the relation between left ventricle contractile reserve and postoperative left ventricular ejection fraction (LVEF). We sought to assess the value of DSH to predict postoperative improvement in LVEF. Methods and Results-Sixty-six consecutive patients with symptomatic severe AS (aortic valve area Յ1 cm 2 ), LVEF Յ40%, and mean pressure gradient Յ40 mm Hg prospectively enrolled in the French multicenter study on low-gradient AS and who survived to aortic valvular replacement (AVR) were included. Preoperative contractile reserve was present in 46 patients (group I; 70%) and absent in 20 patients (group II; 30%). In the overall sample, 58% of patients improved by 2 New York Heart Association (NYHA) classes after AVR. Mean LVEF improved from 29Ϯ6% to 47Ϯ11% (PϽ0.0001). LVEF improved by Ն10 EF units in 38 patients (83%) in group I and in 13 patients (65%) in group II. Mean LVEF improvement was similar in the 2 groups (19Ϯ10% versus 17Ϯ11%; Pϭ0.54). On multivariable analysis, multivessel coronary artery disease (Pϭ0.05) and baseline mean transaortic pressure gradient (Pϭ0.01) were related to LVEF improvement, whereas contractile reserve was not. Conclusions-LVEF increases in the majority of patients with low-gradient AS who survive after AVR. Although the absence of contractile reserve on DSH is related to high operative mortality, it does not predict the absence of LVEF recovery in patients surviving to AVR. These data further support the concept that surgery should not be contraindicated on the basis of absence of contractile reserve alone.

Background-The management of patients with asymptomatic severe aortic stenosis remains controversial. We sought to develop a continuous risk score for predicting the midterm development of symptoms or adverse events in this setting. Methods and Results-We prospectively followed 107 patients with asymptomatic aortic stenosis (aged 72 years [63 to 77]; 35 women; aortic-jet velocity, 4.1 m/s [3.5 to 4.4]) at a single center in France. Predefined end points for assessing outcome were the occurrence within 24 months of death or aortic valve replacement necessitated by symptoms or by a positive exercise test. Variables independently associated with outcome were used to build a score that was validated in an independent cohort of 107 patients from Belgium. Independent predictors of outcome were female sex, peak aortic-jet velocity, and B-type natriuretic peptide at baseline. Accordingly, the score could be calculated as follows: Scoreϭ[peak velocity (m/s)ϫ2]ϩ(natural logarithm of B-type natriuretic peptideϫ1.5)ϩ1.5 (if female sex). Event-free survival after 20 months was 80% for patients within the first score quartile compared with only 7% for the fourth quartile. Areas under the receiver operating characteristic curve for the score were 0.90 and 0.89 in the development and validation cohorts, respectively. Conclusions-If further validation is achieved, this score may be useful to predict outcome in individual patients with asymptomatic aortic stenosis to select those who might benefit from early surgery. (Circulation. 2009;120:69-75.)

No abstract

Background-Intravenous thrombolysis remains a widely used treatment for ST-elevation myocardial infarction; however, it carries a higher risk of reinfarction than primary PCI (PPCI). There are few data comparing PPCI with thrombolysis followed by routine angiography and PCI. The purpose of the present study was to assess contemporary outcomes in ST-elevation myocardial infarction patients, with specific emphasis on comparing a pharmacoinvasive strategy (thrombolysis followed by routine angiography) with PPCI. Methods and Results-This nationwide registry in France included 223 centers and 1714 patients over a 1-month periodat the end of 2005, with 1-year follow-up. Sixty percent of the patients underwent reperfusion therapy, 33% with PPCI and 29% with intravenous thrombolysis (18% prehospital). At baseline, the Global Registry of Acute Coronary Events score was similar in thrombolysis and PPCI patients. Time to initiation of reperfusion therapy was significantly shorter in thrombolysis than in PPCI (median 130 versus 300 minutes). After thrombolysis, 96% of patients had coronary angiography, and 84% had subsequent PCI (58% within 24 hours). In-hospital mortality was 4.3% for thrombolysis and 5.0% for PPCI. In patients with thrombolysis, 30-day mortality was 9.2% when PCI was not used and 3.9% when PCI was subsequently performed (4.0% if PCI was performed in the same hospital and 3.3% if performed after transfer to another facility). One-year survival was 94% for thrombolysis and 92% for PPCI (Pϭ0.31). After propensity score matching, 1-year survival was 94% and 93%, respectively. Conclusions-When used early after the onset of symptoms, a pharmacoinvasive strategy that combines thrombolysis with a liberal use of PCI yields early and 1-year survival rates that are comparable to those of PPCI. (Circulation. 2008;118: 268-276.)

In 13 patients on respiratory support we combined two-dimensional echocardiography with hemodynamic monitoring to determine the mechanism of cyclic changes in arterial pulse, defined as an inspiratory rise in radial artery pulse pressure. Beat-to-beat evaluation of cardiac performance was obtained during the following three distinct consecutive phases of the controlled respiratory cycle: exhalation (phase I), preinspiratory pause (phase LI), and lung inflation (phase III). Airway pressure, left ventricular filling pressure (i.e., pulmonary capillary wedge minus esophageal pressure), and pulmonary artery and radial artery pressures were simultaneously recorded during mechanical ventila-'tion along with beat-to-beat two-dimensional echocardiographic left ventricular end-systolic and enddiastolic dimensions. From a reference value for pulmonary artery and radial artery pulse contour obtained during a brief period of imposed apnea, beat-to-beat measurements of left and right ventricular stroke output were also performed during the controlled respiratory cycle with the pulse contour method. Cyclic changes in arterial pulse appeared to result directly from a transitory increase in left ventricular stroke output during lung inflation (41.4 + 14.6 ml/m2), whereas right ventricular stroke output exhibited a steep fall (31.7 ± 12.4 ml/m2) at this time. An opposite variation was also observed during exhalation, during which a fall in left ventricular stroke output (31.9 ± 11.2 mI/i2) was accompanied by a rise in right ventricular stroke output (38.6 11.9 ml/m2). Both stroke outputs reached an identical level during preinspiratory pause (37.4 + 14. 1 ml/m2 for left ventricle and 39.1 ±-13.8 ml/m2 for right ventricle

Background-Longitudinal myocardial deformation indexes appear superior to left ventricular ejection fraction (LVEF) in assessing myocardial contractility. However, few studies have addressed the prognostic value of longitudinal motion markers (velocity, strain, and strain rate) in predicting outcome in heart failure patients. Methods and Results-The study included 125 consecutive symptomatic heart failure patients (63Ϯ16 years, 77% male, LVEFϭ31Ϯ10%). All patients underwent a complete echocardiographic and clinical examination, and brain natriuretic peptide level was assessed in 93 patients. Longitudinal myocardial velocity by tissue Doppler imaging, global-, and strain rate by speckle tracking were computed from apical views (4-, 3-, and 2-chambers views) and compared with the occurrence of major adverse cardiac events. On the whole, peak longitudinal velocity, global-, and strain rate averaged 5Ϯ2 cm/s (range, 1 to 9), Ϫ8Ϯ3% (range, Ϫ3 to Ϫ18), and Ϫ0.33Ϯ0.16 s Ϫ1 (range, Ϫ0.83 to Ϫ0.05), respectively. During the follow-up period (266Ϯ177 days), major adverse cardiac events occurred in 47 (38%) patients (15 deaths, 29 recurrent heart failure, and 4 heart transplantations). By univariable analysis using Cox model global-, strain rate, and LVEF were associated with the occurrence of major adverse cardiac events, whereas only global-remained independently predictive of outcome by multivariate analysis. Conclusions-In the heart failure population, longitudinal global strain by speckle tracking is superior to LVEF and other longitudinal markers in identifying patients with poor outcome. (Circ Cardiovasc Imaging. 2010;3:249-256.)