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Salihu A, Meier D, Noirclerc N, Skalidis I, Mauler-Wittwer S, Recordon F, Kirsch M, Roguelov C, Berger A, Sun X, Abbe E, Marcucci C, Rancati V, Rosner L, Scala E, Rotzinger DC, Humbert M, Muller O, Lu H, Fournier S. A study of ChatGPT in facilitating Heart Team decisions on severe aortic stenosis. EUROINTERVENTION 2024; 20:e496-e503. [PMID: 38629422 PMCID: PMC11017225 DOI: 10.4244/eij-d-23-00643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 02/01/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Multidisciplinary Heart Teams (HTs) play a central role in the management of valvular heart diseases. However, the comprehensive evaluation of patients' data can be hindered by logistical challenges, which in turn may affect the care they receive. AIMS This study aimed to explore the ability of artificial intelligence (AI), particularly large language models (LLMs), to improve clinical decision-making and enhance the efficiency of HTs. METHODS Data from patients with severe aortic stenosis presented at HT meetings were retrospectively analysed. A standardised multiple-choice questionnaire, with 14 key variables, was processed by the OpenAI Chat Generative Pre-trained Transformer (GPT)-4. AI-generated decisions were then compared to those made by the HT. RESULTS This study included 150 patients, with ChatGPT agreeing with the HT's decisions 77% of the time. The agreement rate varied depending on treatment modality: 90% for transcatheter valve implantation, 65% for surgical valve replacement, and 65% for medical treatment. CONCLUSIONS The use of LLMs offers promising opportunities to improve the HT decision-making process. This study showed that ChatGPT's decisions were consistent with those of the HT in a large proportion of cases. This technology could serve as a failsafe, highlighting potential areas of discrepancy when its decisions diverge from those of the HT. Further research is necessary to solidify our understanding of how AI can be integrated to enhance the decision-making processes of HTs.
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Affiliation(s)
- Adil Salihu
- Department of Cardiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - David Meier
- Department of Cardiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Nathalie Noirclerc
- Department of Cardiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Ioannis Skalidis
- Department of Cardiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Sarah Mauler-Wittwer
- Department of Cardiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Frederique Recordon
- Department of Cardiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Matthias Kirsch
- Department of Cardiovascular Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Christan Roguelov
- Department of Cardiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Alexandre Berger
- Department of Cardiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Xiaowu Sun
- Institute of Mathematics and School of Computer and Communication Sciences, EPFL, Lausanne, Switzerland
| | - Emmanuel Abbe
- Institute of Mathematics and School of Computer and Communication Sciences, EPFL, Lausanne, Switzerland
| | - Carlo Marcucci
- Department of Anesthesiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Valentina Rancati
- Department of Anesthesiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Rosner
- Department of Anesthesiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Emanuelle Scala
- Department of Anesthesiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - David C Rotzinger
- Department of Radiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Marc Humbert
- Department of Geriatrics, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Henri Lu
- Department of Cardiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Skalidis I, Noirclerc N, Meier D, Luangphiphat W, Cagnina A, Mauler-Wittwer S, Mahendiran T, De Bruyne B, Candreva A, Collet C, Sonck J, Muller O, Fournier S. Head-to-head comparison of two angiography-derived fractional flow reserve techniques in patients with high-risk acute coronary syndrome: A multicenter prospective study. Int J Cardiol 2024; 399:131663. [PMID: 38141730 DOI: 10.1016/j.ijcard.2023.131663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/04/2023] [Accepted: 12/18/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND FFRangio and QFR are angiography-based technologies that have been validated in patients with stable coronary artery disease. No head-to-head comparison to invasive fractional flow reserve (FFR) has been reported to date in patients with acute coronary syndromes (ACS). METHODS This study is a subset of a larger prospective multicenter, single-arm study that involved patients diagnosed with high-risk ACS in whom 30-70% stenosis was evaluated by FFR. FFRangio and QFR - both calculated offline by 2 different and blinded operators - were calculated and compared to FFR. The two co-primary endpoints were the comparison of the Pearson correlation coefficient between FFRangio and QFR with FFR and the comparison of their inter-observer variability. RESULTS Among 134 high-risk ACS screened patients, 59 patients with 84 vessels underwent FFR measurements and were included in this study. The mean FFR value was 0.82 ± 0.40 with 32 (38%) being ≤0.80. The mean FFRangio was 0.82 ± 0.20 and the mean QFR was 0.82 ± 0.30, with 27 (32%) and 25 (29%) being ≤0.80, respectively. The Pearson correlation coefficient was significantly better for FFRangio compared to QFR, with R values of 0.76 and 0.61, respectively (p = 0.01). The inter-observer agreement was also significantly better for FFRangio compared to QFR (0.86 vs 0.79, p < 0.05). FFRangio had 91% sensitivity, 100% specificity, and 96.8% accuracy, while QFR exhibited 86.4% sensitivity, 98.4% specificity, and 93.7% accuracy. CONCLUSION In patients with high-risk ACS, FFRangio and QFR demonstrated excellent diagnostic performance. FFRangio seems to have better correlation to invasive FFR compared to QFR but further larger validation studies are required.
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Affiliation(s)
- Ioannis Skalidis
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; School of Medicine, University of Crete, Greece
| | - Nathalie Noirclerc
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - David Meier
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Wongsakorn Luangphiphat
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Aurelien Cagnina
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sarah Mauler-Wittwer
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thabo Mahendiran
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Bernard De Bruyne
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Cardiovascular Center Aalst, Aalst, Belgium
| | - Alessandro Candreva
- Department of Cardiology, University Hospital of Zurich, Zurich, Switzerland
| | | | | | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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Noble S, Mauler-Wittwer S. TAVR as an Alternative to SAVR for Pure Native Aortic Regurgitation. Can J Cardiol 2024; 40:316-325. [PMID: 38016541 DOI: 10.1016/j.cjca.2023.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/06/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023] Open
Abstract
Although transcatheter aortic valve replacement was originally fulfilling an unmet clinical need in the elderly population suffering from tricuspid aortic valve stenosis, its use has been progressively expanded to other groups of patients. In this review, we focus on pure native aortic valve regurgitation, which is in most cases a degenerative disease and therefore frequently diagnosed in elderly patients with comorbidities. Symptoms tend to appear late in the disease, when left ventricular dilation and systolic dysfunction are associated owing to excessive volume overload. It is often combined with a dilated aortic annulus and ascending aorta. Surgical aortic valve replacement remains the criterion standard treatment for severe aortic regurgitation. However, for patients at prohibitive surgical risk, transcatheter aortic valve replacement represents an attractive alternative. Various technical challenges are the absence of calcium at the level of the annulus, which means there are no anchoring points or fluoroscopic landmarks, the difficulty of valve sizing, and the increased stroke volume secondary to the aortic regurgitation, making valve deployment more unstable than in the setting of aortic stenosis. The first-generation transcatheter valves were associated with a higher mortality rate and lower procedural success related to increased risk of paravalvular leak and valve migration requiring a second valve or annular rupture than the more recent off-label or on-label transcatheter valves. Early studies with the dedicated on-label devices showed safety and promising results and will undoubtedly serve in the future a growing number of patients with native aortic regurgitation at prohibitive risk for surgery.
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Affiliation(s)
- Stéphane Noble
- Structural Heart Unit, University Hospital of Geneva, Geneva, Switzerland.
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Mauler-Wittwer S, Giannakopoulos G, Arcens M, Noble S. Degenerated Transcatheter Aortic Valve Replacement: Investigation and Management Options. Can J Cardiol 2024; 40:300-312. [PMID: 38072363 DOI: 10.1016/j.cjca.2023.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 01/16/2024] Open
Abstract
With the expansion of transcatheter aortic valve replacement (TAVR) to younger and lower-surgical-risk patients, many younger and less comorbid patients will be treated with TAVR and are expected to have a life expectancy that will exceed the durability of their transcatheter heart valve. Consequently, the number of patients requiring reintervention will undoubtedly increase in the near future. Redo-TAVR and TAVR explantation followed by surgical aortic valve replacement are the different therapeutic options in the event of bioprosthetic valve failure and the need for reintervention. Patients often anticipate being able to benefit from a redo-TAVR in the event of bioprosthetic valve failure after TAVR, despite the lack of long-term data and the risk of unfavourable anatomy. Our understanding of the feasibility of redo-TAVR is constantly improving thanks to bench test studies and growing worldwide experience. However, much remains unknown. In clinical practice, one of the heart team's objectives is to anticipate the need to reaccess the coronary arteries and implant a second or even a third valve when life expectancy may exceed the durability of the transcatheter heart valve. In this review, we address key definitions in the diagnosis of structural valve deterioration and bioprosthetic valve failure, as well as patient selection and procedural planning for redo-TAVR to reduce periprocedural risk, optimise hemodynamic performance, and maintain coronary access. We describe the bench testing and literature in the redo-TAVR and TAVR explantation fields.
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Affiliation(s)
| | | | - Marc Arcens
- Structural Heart Unit, University Hospital of Geneva, Geneva, Switzerland
| | - Stéphane Noble
- Structural Heart Unit, University Hospital of Geneva, Geneva, Switzerland.
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Noble S, Mauler-Wittwer S. Vascular Closure for Large-Bore Access: Plug-Based or Sutured-Based Vascular Closure Devices? Can J Cardiol 2023; 39:1535-1538. [PMID: 37604408 DOI: 10.1016/j.cjca.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 08/23/2023] Open
Affiliation(s)
- Stephane Noble
- Structural Heart Unit, Cardiology Division, University of Geneva, Geneva, Switzerland.
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Brun G, Carcaterra A, Mauler-Wittwer S, Giannakopoulos G, Pellaton C, Noble S. Platypnea-Orthodeoxia Syndrome Associated With Large Right Ventricular Fibroelastoma Successfully Treated by Transcatheter Approach: A Case Report. CJC Open 2023; 5:805-807. [PMID: 38020331 PMCID: PMC10679450 DOI: 10.1016/j.cjco.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/17/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Grégoire Brun
- Division of Cardiology, Réseau hospitalier neuchâtelois (RHNe), Neuchâtel, Switzerland
| | - Andrea Carcaterra
- Division of Cardiology, Réseau hospitalier neuchâtelois (RHNe), Neuchâtel, Switzerland
| | - Sarah Mauler-Wittwer
- Division of Cardiology, Structural Heart Unit, University Hospital of Geneva (HUG), Geneva, Switzerland
| | - Georgios Giannakopoulos
- Division of Cardiology, Structural Heart Unit, University Hospital of Geneva (HUG), Geneva, Switzerland
| | - Cyril Pellaton
- Division of Cardiology, Réseau hospitalier neuchâtelois (RHNe), Neuchâtel, Switzerland
| | - Stéphane Noble
- Division of Cardiology, Structural Heart Unit, University Hospital of Geneva (HUG), Geneva, Switzerland
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Mauler-Wittwer S, Arcens M, Noble S. [Aortic stenosis: TAVI for all patients?]. Rev Med Suisse 2023; 19:1024-1031. [PMID: 37222642 DOI: 10.53738/revmed.2023.19.828.1024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Over the last 21 years, the paradigm has shifted from an initial use of TAVI for inoperable aortic stenosis cases to recognition of its benefits for all categories of patients. Since 2021, the European Society of Cardiology has recommended first-line transfemoral TAVI from the age of 75 for all categories of patients with aortic stenosis (high, intermediate, low risk). However, in Switzerland, the Federal Office of Public Health currently places a restriction on the reimbursement of low-risk patients, which is expected to be reassessed in 2023. Surgery remains the best therapeutic option for patients with an unfavorable anatomy and for those whose life expectancy exceeds the potential durability of the valve. In this article we will discuss the evidence supporting TAVI, its current indications and initial complications as well as areas for improvement to potentially further expand its indications.
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Affiliation(s)
| | - Marc Arcens
- Service de cardiologie, Hôpitaux universitaires de Genève, 1211 Genève 14
| | - Stéphane Noble
- Service de cardiologie, Hôpitaux universitaires de Genève, 1211 Genève 14
- Responsable de l'Unité de cardiologie structurelle, Service de cardiologie, Hôpitaux universitaires de Genève, 1211 Genève 14
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Noble S, Mauler-Wittwer S, Poku NK. Geographic Determinants of Outcomes After TAVR: Should We Favour Timely Access to TAVR Rather Than High Volume Per Centre? Can J Cardiol 2023; 39:578-580. [PMID: 37173056 DOI: 10.1016/j.cjca.2023.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 03/29/2023] Open
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Noble S, Mauler-Wittwer S, Frangos C, Giannakopoulos G. String Sign and Heart Shape After 34-mm Evolut R Valve Implantation. Can J Cardiol 2023; 39:38-39. [PMID: 36156287 DOI: 10.1016/j.cjca.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/06/2022] [Accepted: 09/16/2022] [Indexed: 01/10/2023] Open
Affiliation(s)
- Stephane Noble
- Department of Medicine, Cardiology Division, Structural Heart Unit, University Hospitals of Geneva, Geneva, Switzerland.
| | - Sarah Mauler-Wittwer
- Department of Medicine, Cardiology Division, Structural Heart Unit, University Hospitals of Geneva, Geneva, Switzerland
| | - Caroline Frangos
- Department of Medicine, Cardiology Division, Structural Heart Unit, University Hospitals of Geneva, Geneva, Switzerland
| | - Georgios Giannakopoulos
- Department of Medicine, Cardiology Division, Structural Heart Unit, University Hospitals of Geneva, Geneva, Switzerland
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Planchat A, Stierlin F, Juillet de Saint-Lager-Lucas A, Peloso A, Mauler-Wittwer S, Noble S. Hydropneumopericardium after pericardiocentesis in a transplant patient. Cardiol J 2023; 30:335-336. [PMID: 37083173 PMCID: PMC10129258 DOI: 10.5603/cj.2023.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 04/22/2023] Open
Affiliation(s)
- Arnaud Planchat
- Department of Medicine, Cardiology Division, Structural Heart Unit, University Hospitals of Geneva, Switzerland.
| | - Florian Stierlin
- Department of Medicine, Cardiology Division, Structural Heart Unit, University Hospitals of Geneva, Switzerland
| | | | - Andrea Peloso
- Department of Surgery, Transplantation Division, University Hospitals of Geneva, Switzerland
| | - Sarah Mauler-Wittwer
- Department of Medicine, Cardiology Division, Structural Heart Unit, University Hospitals of Geneva, Switzerland
| | - Stephane Noble
- Department of Medicine, Cardiology Division, Structural Heart Unit, University Hospitals of Geneva, Switzerland
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Noble S, Mauler-Wittwer S, Meyer P, Giannakopoulos G. Surgical valve replacement in a case of idiopathic dilated cardiomyopathy with massive left atrial dilatation and secondary mitral regurgitation. Cardiol J 2023; 30:333-334. [PMID: 37083172 PMCID: PMC10129252 DOI: 10.5603/cj.2023.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 04/22/2023] Open
Affiliation(s)
- Stephane Noble
- Department of Medicine, Cardiology Division, Structural Heart Unit, University Hospitals of Geneva, Switzerland.
| | - Sarah Mauler-Wittwer
- Department of Medicine, Cardiology Division, Structural Heart Unit, University Hospitals of Geneva, Switzerland
| | - Philippe Meyer
- Department of Medicine, Cardiology Division, Heart Failure Unit, University Hospitals of Geneva, Switzerland
| | - Georgios Giannakopoulos
- Department of Medicine, Cardiology Division, Structural Heart Unit, University Hospitals of Geneva, Switzerland
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Mizuno A, Mauler-Wittwer S, Muller H, Noble S. Recurrent pneumonia post atrial fibrillation ablation: do not forget to look for pulmonary vein stenosis. BMJ Case Rep 2022; 15:15/12/e250896. [PMID: 36593603 PMCID: PMC9730375 DOI: 10.1136/bcr-2022-250896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A man in his 50s presented with persistent chest pain, haemoptysis, cough and dyspnoea 5 months after undergoing catheter ablation for atrial fibrillation (AF). Several chest CT scans suggested pneumonia. Despite adequate treatment for recurrent pneumonia, symptoms persisted. While reviewing the initial chest CT, a partial venous infarction of the left lower lobe associated with severe left inferior pulmonary vein stenosis (PVS) was diagnosed. Stenting of the left inferior pulmonary vein with a vascular bare metal stent was performed, guided by fluoroscopy and transoesophageal echocardiography. Dual antiplatelet therapy (aspirin/clopidogrel) was introduced for 3 months, followed by long-term aspirin monotherapy. The treatment resulted in relief of his symptoms and the resolution of pulmonary opacities on chest CT. Despite low frequency, AF ablation remains the most common cause of acquired PVS. As highlighted in this case, symptoms are not specific and include recurrent pulmonary infection with delayed management.
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Affiliation(s)
- Aki Mizuno
- Department of Cardiology, Geneva University Hospital, Geneva, Switzerland
| | | | - Hajo Muller
- Department of Cardiology, Geneva University Hospital, Geneva, Switzerland
| | - Stephane Noble
- Department of Cardiology, Geneva University Hospital, Geneva, Switzerland
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Adamopoulos D, Pagoulatou S, Rovas G, Bikia V, Müller H, Giannakopoulos G, Mauler-Wittwer S, Licker MJ, Stergiopulos N, Lador F, Noble S. Prognostic Implications of the Novel Pulmonary Hypertension Definition in Patients with Aortic Stenosis after Transcatheter Valve Replacement. J Clin Med 2022; 11:jcm11154279. [PMID: 35893367 PMCID: PMC9332728 DOI: 10.3390/jcm11154279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/08/2022] [Accepted: 07/15/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: Pulmonary hypertension (PH), traditionally defined as a mean pulmonary artery pressure (PAP) ≥ 25 mmHg, is associated with poor outcomes in patients undergoing a transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS). Recently, a novel definition for PH has been proposed, placing the cut-off value of mean PAP at 20 mmHg, and introducing pulmonary vascular resistance as an exclusive indicator for the pre-capillary involvement. In light of the novel criteria, whether PH still preserves its prognostic significance remains unknown. Methods: The study population consisted of 380 patients with AS, who underwent a right heart catheterization before TAVR. The cohort was divided according to the presence of PH (n = 174, 45.7%) or not. Patients with PH were further divided into the following groups: (1) Pre-capillary PH ((Pre-capPH), n = 46, 12.1%); (2) Isolated post-capillary PH ((IpcPH), n = 78, 20.5%); (3) Combined pre and post-capillary PH ((CpcPH), n = 82, 21.6%). The primary endpoint was all-cause mortality at 1 year. Results: A total of 246 patients (64.7%) exhibited mean PAP > 20 mmHg. Overall, the presence of PH was associated with higher 1-year mortality rates (hazard ratio (HR) 2.8, 95% CI: 1.4−5.8, p = 0.004). Compared to patients with no PH, Pre-capPH and CpcPH (but not IpcPH) were related to higher 1-year mortality (HR 2.7, 95% CI: 1.0−7.2, p = 0.041 and HR 3.9, 95% CI: 1.8−8.5, p = 0.001, respectively). This remained significant even after the adjustment for baseline comorbidities. Conclusions: Pre-interventional PH according to the novel hemodynamic criteria, is linked with poor outcomes in patients undergoing TAVR for severe AS. However, this is mainly driven by patients with mean PAP ≥ 25 mmHg. Patients with a pre-capillary PH component as defined by increased PVR present an even worse prognosis as compared to patients with isolated post-capillary or no PH who present comparable 1-year mortality rates.
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Affiliation(s)
- Dionysios Adamopoulos
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
- Correspondence:
| | - Stamatia Pagoulatou
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Georgios Rovas
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Vasiliki Bikia
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Hajo Müller
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
| | - Georgios Giannakopoulos
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
| | - Sarah Mauler-Wittwer
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
| | - Marc-Joseph Licker
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Acute Medicine, Division of Anaesthesiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
| | - Nikolaos Stergiopulos
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Frédéric Lador
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Internal Medicine, Division of Pneumology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
- Pulmonary Hypertension Program, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
| | - Stéphane Noble
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
- Pulmonary Hypertension Program, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
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Pagoulatou S, Adamopoulos D, Rovas G, Bikia V, Müller H, Giannakopoulos G, Mauler-Wittwer S, Licker MJ, Stergiopulos N, Noble S. Arterial Wave Reflection and Aortic Valve Stenosis: Diagnostic Challenges and Prognostic Significance. Front Cardiovasc Med 2022; 9:863968. [PMID: 35872923 PMCID: PMC9304587 DOI: 10.3389/fcvm.2022.863968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionArterial wave reflection is an important component of the left ventricular afterload, affecting both pressure and flow to the aorta. The aim of the present study was to evaluate the impact of wave reflection on transvalvular pressure gradients (TPG), a key parameter for the evaluation of aortic valve stenosis (AS), as well as its prognostic significance in patients with AS undergoing a transcatheter aortic valve replacement (TAVR).Materials and MethodsThe study population consisted of 351 patients with AS (mean age 84 ± 6 years, 43% males) who underwent a complete hemodynamic evaluation before the TAVR. The baseline assessment included right and left heart catheterization, transthoracic echocardiography, and a thorough evaluation of the left ventricular afterload by means of wave separation analysis. The cohort was divided into quartiles according to the transit time of the backward pressure wave (BWTT). Primary endpoint was all-cause mortality at 1 year.ResultsEarly arrival of the backward pressure wave was related to lower cardiac output (Q1: 3.7 ± 0.9 lt/min vs Q4: 4.4 ± 1.0 lt/min, p < 0.001) and higher aortic systolic blood pressure (Q1: 132 ± 26 mmHg vs Q4: 117 ± 26 mmHg, p < 0.001). TPG was significantly related to the BWTT, patients in the arrival group exhibiting the lowest TPG (mean TPG, Q1: 37.6 ± 12.7 mmHg vs Q4: 44.8 ± 14.7 mmHg, p = 0.005) for the same aortic valve area (AVA) (Q1: 0.58 ± 0.35 cm2 vs 0.61 ± 0.22 cm2, p = 0.303). In multivariate analysis, BWTT remained an independent determinant of mean TPG (beta 0.3, p = 0.002). Moreover, the prevalence of low-flow, low-gradient AS with preserved ejection fraction was higher in patients with early arterial reflection arrival (Q1: 33.3% vs Q4: 14.9%, p = 0.033). Finally, patients with early arrival of the reflected wave (Q1) exhibited higher all-cause mortality at 1 year after the TAVR (unadjusted HR: 2.33, 95% CI: 1.17–4.65, p = 0.016).ConclusionEarly reflected wave arrival to the aortic root is associated with poor prognosis and significant aortic hemodynamic alterations in patients undergoing a TAVR for AS. This is related to a significant decrease in TPG for a given AVA, leading to a possible underestimation of the AS severity.
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Affiliation(s)
- Stamatia Pagoulatou
- Laboratory of Hemodynamics and Cardiovascular Technology, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Dionysios Adamopoulos
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Cardiology, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
- *Correspondence: Dionysios Adamopoulos,
| | - Georgios Rovas
- Laboratory of Hemodynamics and Cardiovascular Technology, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Vasiliki Bikia
- Laboratory of Hemodynamics and Cardiovascular Technology, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Hajo Müller
- Department of Cardiology, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | | | - Sarah Mauler-Wittwer
- Department of Cardiology, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | - Marc-Joseph Licker
- Department of Anaesthesiology, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | - Nikolaos Stergiopulos
- Laboratory of Hemodynamics and Cardiovascular Technology, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Stéphane Noble
- Department of Cardiology, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
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Mauler-Wittwer S, Sievert H, Ioppolo AM, Mahfoud F, Carrié D, Lipiecki J, Nickenig G, Fajadet J, Eckert S, Morice MC, Garot P. Study Evaluating the Use of RenalGuard to Protect Patients at High Risk of AKI. JACC Cardiovasc Interv 2022; 15:1639-1648. [DOI: 10.1016/j.jcin.2022.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/17/2022] [Accepted: 05/24/2022] [Indexed: 12/12/2022]
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Mauler-Wittwer S, Noble S. Volume-Outcome Relationship in Surgical and Cardiac Transcatheter Interventions with a Focus on Transcatheter Aortic Valve Implantation. J Clin Med 2022; 11:jcm11133806. [PMID: 35807093 PMCID: PMC9267583 DOI: 10.3390/jcm11133806] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023] Open
Abstract
“Practice makes perfect” is an old saying that can be true for complex interventions. There is a strong and persistent relationship between high volume and better outcomes with more than 300 studies being reported on the subject. The more complex the procedure, the greater the volume-outcome relationship is. Failure to rescue was shown to be one of the factors explaining higher mortality rates post complex surgery. High-volume centers provide a better safety net, thanks to the structure and better protocols, and low-volume operators have better results at high-volume centers than at low-volume centers. Finally, effort should be made to regroup complex procedures in high-volume centers, but without compromising patient access to the procedures. Adaptation to local and geographic constraints is important.
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Affiliation(s)
- Sarah Mauler-Wittwer
- Structural Cardiology Unit, University Hospital of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1205 Geneva, Switzerland;
| | - Stephane Noble
- Structural Cardiology Unit, University Hospital of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1205 Geneva, Switzerland;
- Correspondence:
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Mauler-Wittwer S, Noble S. Coronary Computed Tomographic Angiography Often Allows for the Avoidance of Invasive Coronary Angiography Before Transcatheter Aortic Valve Implantation. Can J Cardiol 2021; 38:1-2. [PMID: 34861378 DOI: 10.1016/j.cjca.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
| | - Stephane Noble
- Structural Cardiology Unit, University Hospital of Geneva, Geneva, Switzerland.
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Abstract
In this state-of-the-art review, we present the findings and a critical analysis of the Leaders Free trial program, evaluating outcomes of a new stent-generation based on polymer-free technology, in this case the BioFreedom™ (Biosensors Europe, Switzerland), in patients at high bleeding risk (HBR). Polymer-free drug-coated stents were designed to obtain a device with the antirestenotic benefits of drug-eluting stents but without the polymer coating as potential trigger for delayed arterial wall healing and subsequent late ischemic adverse events, causing a prolonged dependence on dual antiplatelet therapy after stenting. This offers therefore the potential of a promising device-based strategy in a complex growing population of patients with combined HBR and high thrombosis risk, due to the possible reduction of antithrombotic duration.
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Affiliation(s)
- Sarah Mauler-Wittwer
- Hôpital Privé Jacques Cartier, Institut Cardio-vasculaire Paris-sud (ICPS), Ramsay-Santé, Massy, France
| | - Philippe Garot
- Hôpital Privé Jacques Cartier, Institut Cardio-vasculaire Paris-sud (ICPS), Ramsay-Santé, Massy, France
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