Limbic encephalitis secondary to neuro-Behcet disease: an uncommon presentation

INTRODUCTION

Limbic encephalitis (LE) can have a wide range of etiologies, most frequently infectious (especially viral) or autoimmune. Behcet's disease (BD) can present with heterogeneous neurological manifestations. However, LE is not considered a typical presentation of neuro-Behcet's disease (NBD).

CASE REPORT

A 40-years-old male presented with new-onset subacute headaches, memory problems and apathy. A review of systems revealed an unrecorded past history of recurrent oral sores for years, recent malaise and fever, as well as an episode of bilateral panuveitis four months before presentation. His general and neurologic examination revealed slight fever, an isolated oral aphtha, anterograde amnesia and signs of bilateral retinal vasculitis. Brain magnetic resonance imaging displayed a pattern of limbic meningoencephalitis, and his cerebrospinal fluid showed mononuclear inflammation. The patient met BD diagnostic criteria. Considering LE is a very rare presentation of NBD, alternative etiologies were thoroughly assessed and excluded, including infectious, autoimmune and paraneoplastic encephalitis. Therefore, he was diagnosed with NBD, and he recovered well after immunosuppression.

DISCUSSION

Only two cases of NBD presenting with LE have been previously reported. We report a third case of this rare presentation and compare it with the previous two. We aim to highlight this association and contribute to enlarge the rich clinical spectrum of NBD.

Automated Global Longitudinal Strain Assessment in Long-Term Survivors of Childhood Acute Lymphoblastic Leukemia

There is limited evidence that supports the use of the global longitudinal strain (GLS) in long-term cardiac monitoring of childhood acute lymphoblastic leukemia survivors (CLSs). Our aim was to assess the utility of automated GLS to detect left ventricular systolic dysfunction (LVSD) in long-term CLSs. Asymptomatic and subclinical LVSD were defined as LVEF < 50% and GLS < 18.5%, respectively. Echocardiographic measurements and biomarkers were compared with a control group. Inverse probability weighting was used to reduce confounding. Regression models were used to identify factors associated with LVEF and GLS in the survivors. Ninety survivors with a median follow-up of 18 (11−26) years were included. The prevalence of LVSD was higher using GLS than with LVEF (26.6% vs. 12.2%). The measurements were both reduced as compared with the controls (p < 0.001). There were no differences in diastolic parameters and NT-ProBNP. Survivors were more likely to have Hs-cTnI levels above the detection limit (40% vs. 17.2%, p = 0.006). The dose of anthracycline was associated with LVEF but not with GLS in the survivors. Biomarkers were not associated with GLS or LVEF. In conclusion, LVSD detection using automated GLS was higher than with LVEF in long-term CLSs. Its incorporation into clinical routine practice may improve the surveillance of these patients.

Correlation between atrial electrocardiographic indexes and left atrial enlargement in competitive athletes. From the ALMUDAINA case-control study

Background

Left atrial (LA) remodelling and enlargement in athletes is a well-kown component of the athlete's heart. However, information about the correlation between of LA enlargement and atrial electrophysiological features in athletes is scarce.

Purpose

Our aim was to characterize LA enlargement, P-wave duration, and the prevalence of interatrial block (IAB) in competitive athletes (with and without LA enlargement) and in controls.

Methods

ALMUDAINA (Analysis of Left atrial Measurements of Ultrasound Dilation Among International and National Athletes) was a nationwide, cross-sectional study involving 9 hospitals and sport clinics across Spain. Cases fulfilled the international consensus definition of a competitive athlete and were currently engaged in skill, power, mixed or endurance disciplines at a national or international level. The following P-wave parameters were analysed: 1) duration 2) voltage in lead I and 3) the presence of interatrial block (IAB). LA enlargement was defined as an indexed volume by body surface area ≥34 ml/m2, measured by transthoracic echocardiography. A contemporary cohort of otherwise healthy and active controls was used as a comparison group.

Results

Baseline clinical and echocardiographic characteristics of both cohorts are summarised in table 1 whereas electrocardiographic characteristics are displayed in table 2, respectively. 356 subjects were included, 308 athletes (mean age: 36.4±11.6 years) and 48 controls (mean age: 49.3±16.1 years). Athletes showed a higher mean LA indexed volume (29.8±8.6 vs. 25.6±8.0 mL/m2, P=0.006) and higher prevalence of LA enlargement (113 [36.7%] vs. 5 [10.4%], P&lt;0.001), but there were no relevant differences in P-wave duration (106.3±12.5 ms vs 108.2±7.7 ms; P=0.31), voltage in lead I (0.08±0.04 vs. 0.08±0,04 mV; P=0.79) and the prevalence of IAB (40 [13.0%] vs. 4 [8.3%], P=0.36). Only a case of advance IAB was detected, in an athlete without LA enlargement. Among athletes, those with LA enlargement (113, 36.7%) had higher P-wave duration (110.3±14.1 vs. 103.0±10.9 ms, P&lt;0.001) and a higher prevalence of interatrial blockade (23 [20.4%] vs. 17 [8.8%], P=0.004), but similar voltage of P-wave in lead I (0.08±0.003 vs. 0.08±0.05 mV, P=0.689). In a multivariate analysis, competitive training was independently associated with LA enlargement (odds ratio [OR] 14.7, 95% confidence interval [CI] 4.7–44.0; P&lt;0.001) but was not associated with P-wave duration (OR 1.02, 95% CI: 0.99–1.04; P=0.19) or IAB (OR 1.4, 95% CI 0.7–3.1; P=0.34).

Conclusions

LA enlargement is prevalent in adult competitive athletes. However, ECG indexes of atrial electrophysiology were not different from healthy controls. Our data suggest that LA enlargement and IAB are two different entities.

Funding Acknowledgement

Type of funding sources: None.

Rationale and design of the rigorous atrial analysis in advanced interatrial block (ARABIA) prospective study

BACKGROUND

Advanced interatrial block (IAB) is present in 10% of subjects ≥75 years and is associated with the risk of clinical events.

METHODS AND RESULTS

Prospective multicenter study that will include subjects ≥75 years without exclusion criteria (indication for anticoagulation, cardiac devices, severe valve disease, systolic dysfunction, moderate or severe cognitive impairment, poor echocardiographic window, non-sinus rhythm or partial IAB, stroke, and life expectancy <2 years). A total of 356 subjects, 178 patients with advanced IAB (exposed) and 178 matched individuals with normal P-wave (non-exposed) will be included. Electrocardiogram and advanced transthoracic echocardiography will be performed. Two substudies will include magnetic resonance imaging: cardiac (86 subjects, 43 exposed, and 43 non-exposed) and brain (86 subjects, 43 exposed, and 43 non-exposed). The follow-up will be 2 years. Our main objective is to determine the association of advanced IAB, P-wave duration, and atrial imaging parameters (I] atrial global longitudinal strain, II] maximal left atrial volume index, III] left atrial ejection fraction, IV] left atrial fibrosis - % total left atrial area V] inter- and intra-atrial asynchrony/dyssynchrony) with clinical events (atrial fibrillation, stroke, cognitive impairment, and mortality). The secondary objective is to assess the association of the P-wave duration with atrial imaging parameters and of both with cerebral microemboli in magnetic resonance imaging.

CONCLUSION

Our study will provide data regarding the association of advanced IAB, P-wave duration, and atrial imaging parameters with clinical events. We will also assess the association P-wave duration-atrial imaging parameters-cerebral microemboli.

[From in-person didactic sessions to videoconferencing during the COVID-19 pandemic: satisfaction survey among participants]

INTRODUCTION AND AIM

COVID-19 pandemic has disturbed many hospital activities, including medical education. We describe the switch from in-person didactic sessions to videoconferencing in a Neurology department. We analyse the opinions and satisfaction of participants.

MATERIAL AND METHODS

Narrative description of the adopted measures; Online survey among participants.

RESULTS

One of the three weekly sessions was cancelled, and two switched to videoconferencing. There were more participants online than in the conference hall. 49 users answered the survey, 51% women, mean age 40.5 years (range 25-65). Satisfaction was higher for previous face-to-face meetings (8.68) than for videoconferencing (8.12) (p=0.006). There was a significant inverse correlation between age and satisfaction with virtual sessions (r=-0.37; p=0.01), that was not found for in-person attendance. Most users (75.5%) would prefer to continue with online sessions when the pandemic is over, and 87.8% support inter-hospital remote meetings, but the safety of web platforms is a concern (53.1%).

CONCLUSIONS

The change from in-person to virtual sessions is an easy measure to implement in a neurology department, with a good degree of satisfaction among users. There are some unsolved problems with the use of commercial web platforms and inter-hospital connection. Most users recommend leadership and support from educational and health authorities.

Serum and CSF alpha-synuclein levels do not change in COVID-19 patients with neurological symptoms

SARS-CoV-2 infection can associate diverse neurological manifestations. Several studies have provided proof to support the theory of neurotropic involvement of SARS-CoV-2. Alpha-synuclein has been described as a native antiviral factor within neurons, and upregulation of this protein can be seen in animals that suffered other neuroinvasive infections. To assess if increased expression of this protein takes place in COVID-19 patients with neurological symptoms, we analyzed serum total alpha-synuclein levels in three groups: seven COVID-19 patients with myoclonus, Parkinsonism and/or encephalopathy; thirteen age- and sex-matched COVID-19 patients without neurological involvement and eight age- and sex-matched healthy controls. We did not find differences among them. In a subset of four patients, the change in serum alpha-synuclein before and after the onset of neurological symptoms was not significant either. Cerebrospinal fluid alpha-synuclein levels were also similar between neurological COVID-19 and healthy controls. Overall, these results cannot support the hypothesis of alpha-synuclein upregulation in humans with neurological symptoms in COVID-19. Further research taking into account a larger group of COVID-19 patients including the whole spectrum of neurological manifestations and disease severity is needed.

Trends in hospitalization and in-hospital mortality of patients with heart failure in Spain. A population-based study (2003–2015)

Background

Heart failure (HF) is one of the most pressing current public health concerns. However, in Spain there is a lack of population data.

Purpose

To investigate trends in HF hospitalization and in-hospital mortality rates.

Methods

We conducted a retrospective observational study of patients discharged with the principal diagnosis of HF from The National Health System' acute hospitals during 2003–2015. The source of the data was the Minimum Basic Data Set of the Ministry of Health, Consumer and Social Welfare. We analyzed trends in hospital discharge rates for HF (discharge rates were weighted by age and gender) an in-hospital mortality. The risk-standardized in-hospital mortality ratio (RSMR) was defined as the ratio between predicted mortality (which individually considers the performance of the hospital where the patient is attended) and expected mortality (which considers a standard performance according to the average of all hospitals) multiplied by the crude rate of mortality. RSMR was calculated using a risk adjustment multilevel logistic regression models developed by the Medicare and Medicaid Services. Temporal trend during the observed period was modelled using Poisson regression analysis with year as the only independent variable. In this model, the incidence rate ratio (IRR) and their 95% confidence intervals (95% CI) was calculated.

Results

A total of 1 254 830 episodes of HF were selected. Throughout 2003–2015 the number of hospital discharges with principal diagnosis of HF increased by 61% (IRR: 1.04; CI: 1.03–1.04; p&lt;0.001), meanwhile the crude mortality rate and the mean length of stay (LOS) diminished significantly (IRR: 0.99; CI: 0.98–1; and IRR: 1.04; CI: 0.99–0.99; p&lt;0.001, for both). Discharge rates weighted by age and sex showed a statistically significant increase during the period (IRR: 1.03; CI: 1.03–1.03; p&lt;0.001); however, whereas discharge rates increased significantly in older groups of age (≥75 years old) (IRR: 1–1.02; p&lt;0.001) they diminished in younger groups of age (45–74 years old) (IRR: 0.99; p&lt;0.001 and there was not a significant trend in the discharge rates for the group of 35–44 years old (Figure). The risk-standardized in-hospital mortality ratio did not significantly change throughout 2003–2015 (IRR: 0.997; CI: 0.992–1; p=0.32), however the risk-standardized LOS ratio diminished from 1.07 in 2003 to 0.97 in 2015 (IRR: 0.98: IC: 0.98–0.99; p&lt;0.001).

Conclusions

From 2003 to 2015, HF admission rate increased significantly in Spain as a consequence of the sustained increase of hospitalization in the population over 75. The crude in-hospital mortality rate diminished significantly for the same period, but the risk-standardized in-hospital mortality ratio did not significantly change.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of hospital volume on in-hospital mortality and 30-day cardiac readmission of hospitalized patients with heart faliure. A population based study

Background

Heart failure (HF) is a major health care problem. Epidemiological data from hospitalized patients are scarce and the association between hospital volume and patient outcomes is largely unknown.

Purpose

The aim of this study was to analyze the relationship between hospital volume and outcomes (in-hospital mortality and 30-day cardiac readmission).

Methods

We conducted an observational study of patients discharged with the principal diagnosis of HF from The National Health System' acute hospitals during 2015. The source of the data was the Minimum Basic Data Set of the Ministry of Health, Consumer and Social Welfare. We calculated risk-standardized mortality rates (RSMR) at the index episode and risk-standardized cardiac diseases readmissions rates (RSRR) within 30 days after discharge by using a risk adjustment multilevel logistic regression models developed by the Medicare and Medicaid Services. Information on the number of HF discharges at each hospital in 2015 was analysed to classify centres into 2 categories (high- and low-volume hospitals). To discriminate between high- and low-volume centers, a K-means clustering algorithm was used. The association between volume and RSMR or RSRR was tested with the Pearson correlation coefficient and linear regression models.

Results

A total of 117 233 episodes of HF were selected during 2015. The mean age was 80±10 years and 46% were women. The crude in-hospital mortality rate was 12.1% and 30-day cardiac readmission rate was 18%. The cut-off point was set at 517 HF discharges per hospital during 2015. High volume hospitals had a statistically lower RSMR (10.3±2.8 vs 11.3±3.6; p&lt;0.001) and higher RSRR (10.7±1.9 vs 9.2±1.6; p&lt;0.001) than low volume hospitals. Low-volume hospitals showed higher dispersion of outcomes than high-volume, both for RSMR and RSRR (Figure).

Conclusions

We found that patients hospitalized for HF in 2105 had lower in-hospital mortality if they were admitted to a high-volume hospital. We have also found that high-volume hospitals had higher 30-day cardiac readmission rates.

Funding Acknowledgement

Type of funding source: None

P1515Female sex is an independent predictor of mortality in patients with STEMI in Spain: a study in 325,017 episodes over 11 years (2005–2015)

Background

Recent studies reported a decrease in the mortality of ST-elevation myocardial infarction (STEMI) patients. This favorable evolution could not extend to women. The interaction between gender and mortality in STEMI remains controversial.

Purpose

To assess the impact of female sex on mortality of patients with STEMI through of period of 11 years.

Methods

We conducted a retrospective longitudinal study using information provided by the minimal database system of the Spanish National Health System to identify all hospitalizations in patients aged 35–94 years with the principal diagnosis of STEMI from 2005–2015.

Results

A total of 325,017 STEMI were identified. Of them, 273,182 were included, and 106,277 (38.8%) were women. Women were older than men and had more comorbidities. Through the study period 53% men vs 37.2% underwent PTCA; women presented more frequently heart failure, shock and stroke than men (p<0.001, respectively). The mean crude in-hospital mortality rate for the whole study period was higher in women (OR: 2.18; 95% CI: 2.12.-2.23, p<0.0001). Female sex was independently associated with higher in-hospital mortality (adjusted OR: 1.18; 95% CI: 1.14–1.22, p<0.001) (Table 1). The risk was maintained through the whole study period (lower OR: 1.14 in 2014; higher OR: 1.28 in 2006).

Table 1. Variables independently associated with in-hospital mortality adjusted by risk in a multilevel logistic regression model, 2005–2015 STEMI In-hospital mortality Odds Ratio P 95% CI Woman 1.18 <0.001 1.14 1.22 Age 1.06 <0.001 1.06 1.06 History of PTCA 1.58 <0.001 1.40 1.77 Congestive heart failure 1.26 <0.001 1.22 1.30 Acute Myocardial Infarction 1.84 <0.001 1.54 2.20 Anterior myocardial infarction 1.47 <0.001 1.23 1.76 Cardio-respiratory failure or shock 15.25 <0.001 14.78 15.75 Hypertension 0.81 <0.001 0.79 0.84 Stroke 5.76 <0.001 5.18 6.42 Cerebrovascular disease 0.86 <0.001 0.79 0.93 Renal failure 1.95 <0.001 1.88 2.02 Vascular disease and complications 7.03 <0.001 5.72 8.63 CI, Confidence Interval.

Conclusions

Female sex is an independent predictor of mortality in patients with STEMI in Spain, maintaining through a period of the 11 years.

P3605Lower benefit of women than men with ST-elevation myocardial infarction networks system in Spain: a study of 325,017 episodes over 10 years (2005–2015)

Background

Sex differences are known to exist in the management of women presenting with ST elevation myocardial infarction (STEMI).Few studies have examined whether the clinical management and prognosis differs by sex when the STEMI network system is applied.

Purpose

To assess whether the STEMI network system improves management and prognosis both in men and women in Spain and to analyze possible differences according to sex.

Methods

We conducted a retrospective longitudinal study using information provided by the minimal database system (MDBS) of the Spanish National Health System (SNHS) to identify all hospitalizations in patients aged 35–94 years with the principal diagnosis of STEMI from 2005–2015. The risk-standardized in-hospital mortality ratio (RSMR) was defined as the ratio between predicted mortality and expected mortality, multiplied by the crude rate of mortality. The RSMR was calculated using multilevel risk adjustment models developed by the Medicare and Medicaid Services. The year of the development of organized systems of care for STEMI patients in the different Autonomous Communities was double-checked using data from the National Cardiac Catheterization and Interventional Cardiology Annual Registry. RSMR was used to compare outcomes related with gender and with the presence of regional AMI networks and the performance of PCI. Temporal trends for in-hospital mortality during the observed period were modeled using Poisson regression analysis with year as the only independent variable. In all models, incidence rate ratios (IRR) and their 95% confidence intervals (95% CI) were calculated.

Results

A total of 325,017 STEMI were identified among patients aged 35–94 years old. Of them 273,182 were selected after exclusions, and 106,277 (38.8%) were women. Women were on average 10 years older than men and had more comorbidities burden. The overall proportion of STEMI patients underwent to PCI increased, when a regional STEMI network was present from 2005–2015: (63.7% vs 48.2% in men; and 47.4% vs 32.9% in women; p<0.001). Differences in crude mortality between sexes was 15%, maintaining through 10 years, despite a higher increased of PCI (figure 1).However, women were less likely to be treated with PCI even though when STEMI network was stablished (63.7% vs 48.2% in men, 47.4% vs 32.9% in women, p<0.001) (figure 1).The mean crude in-hospital mortality rate for the whole study period was higher in women (9.3% vs 18.3%; unadjusted OR: 2.18, 95% CI: 2.12.-2.23, p<0.0001). RSMR was lower for women when STEMI network were working (17.7% vs. 19.7%; p<0.001).PCI and the presence of STEMI network were associated with a lower in-hospital mortality in STEMI women (adjusted OR, 0.48; 95% CI 0.41–0.52 and OR, 0.84; 95% CI 0.79–0.89, p<0.001, respectively).

Conclusions

Women were less likely to be treated with PCI and had higher in-hospital risk-adjusted mortality than men, despite the existence of STEMI network system.

P4800Estimated effect of NOACs compared to Vitamin K Antagonists in real-world atrial fibrillation patients: Data from FANTASIA Registry

Background

Despite of the effectiveness and safety profile of Non-vitamin K Antagonists Oral Anticoagulants (NOACs) even in real-world (RW) Atrial Fibrillation (AF) patients, Vitamin K Antagonists (VKAs) have remained widely used in clinical practice worldwide but the comparison with acenocoumarol therapy in RW is unknown.

Purpose

To estimate the potential absolute benefit in clinical adverse events if the AF patients anticoagulated with VKA therapy had been treated with NOACs.

Methods

We analyzed anticoagulated AF patients who were prospectively recruited into the multicentre FANTASIIA registry. Patients were treated with VKAs for at least 6 months prior to inclusion. The estimation of clinical adverse events avoided was calculated applying absolute risk reductions, relative risk reductions and hazard ratios from the meta-analysis of RW use of NOACs relative to VKAs.

Results

We analyzed 1,470 patients under VKA therapy (mean age 74.1±9.5 years; 56.4% male). Stroke rate with acenocoumarol treatment was 0.88%/year. The estimated rates for stroke using NOACs would be 0.80%/year for Dabigatran 150 mg; 0.76%/year for Rivaroxaban and 0.74%/year for Apixaban instead of VKA. No significant differences were observed between the different NOACs and VKA in stroke rate. Major bleeding with acenocoumarol was 3.40%/year. The estimated rates for major bleeding using NOACs would be 2.75%/year for Dabigatran 150 mg; 3.37%/year for Rivaroxaban and 2.18%/year for Apixaban instead of VKA. Apixaban was the only NOAC that showed a significant estimated reduction rates (p=0.046). Finally, the all-cause mortality rate with acenocoumarol was 4.69%/year. The estimated rates of all-cause mortality using NOACs would be 3.28%/year for Dabigatran 150mg; 4.88%/year for Rivaroxaban and 2.67%/year for Apixaban. Dabigatran and Apixaban showed significant estimated reduction rates with the highest reduction with Apixaban (Table).

Annual Rate reduction of adverse events

Conclusion

The absolute estimated effect of NOACs in the AF patients anticoagulated with VKA showed a significant reduction in adverse clinical events. Apixaban performed the highest estimated reduction in major bleeding and all-cause mortality in comparison with acenocoumarol.

P3707CHA2DS2 VASC score as predictor of the incidence of stroke in patients with stable coronary artery disease and sinus rhythm in the long-term follow-up

Background

Cerebral vascular disease and coronary artery disease (CAD) share risk factors. Our aim was to study CHA2DS2VASC score as predictor of stroke incidence in a sample of patients with sinus ryhtm and stable CAD (sCAD) during long term follow-up.

Methods

The CICCOR registry (“Chronic ischaemic heart disease in Cordoba”) is a prospective monocentric cohort study. Between February 2000 and January 2004 all patients with sCAD who attended two outpatient cardiology clinics in a city of the South of Spain were recruited. We analyzed the relationship between baseline CHA2DS2VASC score and the incidence of stroke in a sample of patients with sCAD without atrial fibrillation during long term follow-up. Patients without sinus rythm were excluded.

Results

1268 patients with sCAD were recruited (median age 68±10 years, 73% male). 69 patients showed atrial fibrillation and were excluded. The median follow-up was 11.2 years (maximum follow-up of 17 years). During this period, only 2 patients were lost, and 136 patients (11.5% of the sample) suffered stroke. Baseline mean CHA2DS2 VASC score was 3.21. Most patients showed CHA2DS2 VASC score lower than 4 (81.4% of the sample). Higher CHA2DS2 VASC score at baseline was associated with higher risk of suffering stroke during follow-up (Hazard Ratio = 1.31 (1.16–1.48); p<0.001). Mean results are shown in the table.

Table 1 No stroke (n=1063) Stroke (n=136) Hazard ratio (CI 95%) p Sex male (%) 777 (88.8) 98 (11.2) High blood pressure (%) 561 (86.6) 86 (13.3) Diabetes mellitus (%) 317 (86.4) 50 (13.6) 75 years and older (%) 205 (83.7) 40 (16.3) Mean CHADS VASC score 3.17 3.55 1.31 (1.16–1.48) <0.001 CHADS VASC score higher than 4 (%) 185 (84.1) 35 (15.9) 2.00 (1.33–3.01) 0.001

Stroke incidence according to CHADSVASC

Conclusion

Higher CHA2DS2 VASC score was significantly associated with higher stroke incidence during long term follow-up in this real-world sample of patients with sCAD in sinus rythm.

Mitral regurgitation during transcatheter aortic valve implantation: the same complication with a different mechanism

AIMS

Mitral regurgitation (MR) is a complication that may occur during transcatheter aortic valve implantation (TAVI) in a certain percentage of cases and may require different treatments depending on the mechanism. Our purpose was to describe the occurrence rate of this complication during TAVI with the CoreValve prosthesis, as well as to assess the usefulness of transesophageal echocardiogram (TEE) in the detection of the mechanism of MR.

METHODS AND RESULTS

We analyzed a total of 129 cases of severe aortic stenosis treated with CoreValve prosthesis from June 2008 to October 2011. We defined a significant MR after TAVI as grade III MR or higher, considering either the new appearance of MR or the worsening of a preexisting MR, as assessed by both TEE and angiography. In our series, there was a total of 11 cases of significant MR after TAVI (8.5%). Angiography detected 100% of the MR cases, but was unable to determine the mechanism of MR in any case. TEE, on the other hand, determined 100% of the MR cases, and determined that 1 case was caused by mechanical asynchrony due to a new left bundle branch block, 3 cases were due to an aortic prosthesis impingement on the anterior mitral leaflet, 2 cases were due to the appearance of a systolic anterior movement of the anterior mitral leaflet with dynamic obstruction of the left ventricular outflow tract, 1 case was caused by a commissural tearing of the valve, and 4 cases were explained by a "functional" mechanism, probably due to transient damage of the subvalvular mitral apparatus by the delivery system. All cases had an MR grade II or less as evidenced by transthoracic echocardiography at discharge. Surgery was not required in any case. Knowledge of the mechanism of MR made it possible to provide the best treatment option in each case.

CONCLUSION

There is a certain percentage of patients treated with CoreValve prosthesis who develop significant MR during the procedure. TEE, unlike angiography, can define the very diverse mechanisms of MR in 100% of cases, and elucidates the best approach to this complication. Surgery was not required in any case.