cours de cardiologie

1. QUOI DE NEUF?
Dr SIHAM HALLAB
Service de cardiologie-Pr Rachida Habbal
CHU Ibn Rochd casablanca

3. Rétrécissement aortique à bas débit et bas
gradient malgré une fraction d’éjection normale
« low flow low gradient aortic stenosis » :
faut-il opérer ?
• prévalence :25 à 35 %(selon plusieurs études)
• Se caractérise par: une surface valvulaire aortique ≤ 1cm², un
gradient moyen transvalvulaire ≤ 40 mmHg, une FeVG
préservée (≥ 50 %) et un volume d’éjection indexé par
rapport à la surface corporelle ≤ 35 ml/m².
• concerne souvent les sujets âgés, de sexe féminin, HTA avec
un remodelage concentrique prononcé (rapport paroi/cavité
> 0,47), et une petite cavité ventriculaire gauche (DTDVG ≤
47 mm), à l’origine d’une anomalie de remplissage
diastolique.
• Entité Problème à la fois du diagnostic et de la
prise en charge thérapeutique:

4. QUE FAIRE?

7. Minners and al. Eur Heart J. 2008

8. • Calcifications:
« look at the valve »
ETT, scopie
scanner: score
calcique
• +/- Echo Dobutamine low
dose
• +/- BNP
• +/- KT: Gorlin

9. faut-il opérer ?
ESC 2012
class level
AVR should be considered in symptomatic
patients with low flow, low gradient (<40 mmHg) AS
with normal EF only
after careful confirmation of severe AS.
IIa C

12.  1ère implantation :Rouen en avril 2002.
 Deux valves aortiques implantables
par voie percutanée sont
commercialisées en Europe depuis
2007:
 la valve Edwards (Edwards Lifesciences,
Irvine, California)
 la Corevalve (Medtronic, Irvine,
California)
 Voies d’abord:
 voie artérielle fémorale
 2ème intention: voie transapicale, voie
artérielle sous clavière
 Plusieurs registres: PARTNER,
France 2,
GARY (ESC 2012)

19. TAVI should only be undertaken with a multidisciplinary ‘heart team’
including cardiologists and cardiac surgeons and other specialists if
necessary.
I C
TAVI should only be performed in hospitals with cardiac surgery on-site.
I C
TAVI is indicated in patients with severe symptomatic AS who are not
suitable for AVR as assessed by a ‘heart team’ and who are likely to gain
improvement in their quality of life and to have a life expectancy of more
than 1 year after consideration of their comorbidities.
I B
TAVI should be considered in high-risk patients with severe symptomatic AS
who may still be suitable for surgery, but in whom TAVI is favoured by a
‘heart team’ based on the individual risk profile and anatomic suitability.
IIa B

27. Critères échographiques de la sévérité des
régurgitations

33. Mitraclip
réparation « bord à bord »
• Introduite par Alfieri
• peu diffusée et l’est
essentiellement dans l’IM
dégénérative
• Le seul système utilisé en clinique
est le système Mitraclip (Abbott
Vascular,)
• Plusieurs études: EVEREST,
REALISM,
ACCESS Europe

36. ACCESS-EUROPE Phase I
A Post Market Study of the MitraClip System for
the Treatment of Significant Mitral
Regurgitation in Europe: Analysis of Outcomes
at 1 Year
Wolfgang Schillinger, MD
on behalf of the ACCESS EU investigators
European Society of Cardiology Congress 2012
Munich, Germany

37. Baseline Demographics and Co-Morbidities
Demographics and Co-morbidities
EVEREST II RCT
Device Patients
N=178
EVEREST II High
Surgical Risk
Cohort
N=211
ACCESS EU –
MitraClip Patients
N=567
Age (mean ± SD), years 67 ± 13 76 ± 10 74 ± 10
Logistic EuroSCORE, (%)
Mean ± SD NA NA 23 ± 18
Logistic EuroSCORE ≥ 20%, (%) NA NA 45
STS Mortality Risk, (%)
Mean ± SD 5 ± 4 12 ± 8 NA
STS Mortality Risk ≥ 12%, (%) 6 48 NA
Male Gender, (%) 64 61 64
Coronary Artery Disease, (%) 47 81 63
Previous Cardiovascular Surgery, (%) 23 58 37
Myocardial Infarction, (%) 22 49 32
Cerebrovascular Disease, (%) 8 21 13
Moderate to Severe Renal Failure, (%) 3 31 42
Atrial Fibrillation, (%) 33 64 68
NYHA Functional Class III or IV, (%) 50 86 85
ACCESS EU-ESC2012

38. Site Reported Safety Events At 30 Days
1-Year Events*
All Patients
N=567
Logistic
EuroSCORE ≥20%
N=253
Logistic
EuroSCORE <20%
N=314
p-value
Death 19 (3.4%) 11 (4.3%) 8 (2.5%) ns
Stroke 4 (0.7%) 3 (1.2%) 1 (0.3%) ns
Myocardial
4 (0.7%) 2 (0.8%) 2 (0.6%) ns
Infarction
Renal Failure 27 (4.8%) 16 (6.3%) 11 (3.5%) ns
Respiratory Failure 4 (0.7%) 3 (1.2%) 1 (0.3%) ns
Need for
Resuscitation
10 (1.8%) 7 (2.8%) 3 (1.0%) ns
Cardiac Tamponade 6 (1.1%) 3 (1.2%) 3 (1.0%) ns
Bleeding
22 (3.9%) 12 (4.7%) 10 (3.2%) ns
Complications
ACCESS EU-ESC2012

39. Site Reported Safety Events At 1 Year
1-Year Events*
All Patients
N=567
Logistic
EuroSCORE ≥20%
N=253
Logistic
EuroSCORE <20%
N=314
p-value
Death 98 (17.3%) 58 (22.9%) 40 (12.7%) <0.05
Stroke 6 (1.1%) 4 (1.6%) 2 (0.6%) ns
Myocardial
8 (1.4%) 5 (2.0%) 3 (1.0%) ns
Infarction
Renal Failure 49 (8.6%) 29 (11.5%) 20 (6.4%) <0.05
Respiratory Failure 5 (0.9%) 4 (1.6%) 1 (0.3%) ns
Need for
12 (2.1%) 9 (3.6%) 3 (1.0%) <0.05
Resuscitation
Cardiac Tamponade 7 (1.2%) 4 (1.6%) 3 (1.0%) ns
Bleeding
27 (4.8%) 16 (6.3%) 11 (3.5%) ns
Complications
ACCESS EU-ESC2012

40. Mitral Regurgitation Grade*
2+ 0
1+
2+
N = 327 Matched Cases
79% MR ≤ 2+
at 1 Year
100
80
60
40
20
0
Baseline 1 Year
Percent Patients
3+
4+
3+
4+
p<0.0001
ACCESS EU-ESC2012

41. NYHA Functional Class
72% NYHA
Class I or II
at 1 Year
I
N = 343 Matched Cases
100
80
60
40
20
0
Baseline 1 Year
Percent Patients
II
III
IV
II
III
IV
I
p<0.0001
ACCESS EU-ESC2012

42. Quality of Life Score (MLHFQ) and
6-Minute Walk Distance
MLHFQ
Mean improvement -13.5 points
95% CI: (-16.0, -11.0)
41,6
28,1
60
45
30
15
0
Mean QoL Score (MLHFQ)
p<0.0001
Baseline 1 Year
N = 264 Matched Cases
6MWT
Mean improvement 59.5 meters
95% CI: (44.5, 74.6)
275
334
400
300
200
100
0
Mean Meters Walked
p<0.0001
Baseline 1 Year
N = 216 Matched Cases
ACCESS EU-ESC2012

43. principales approches percutanées pour le
traitement de l’IM
Kardiovaskuläre Medizin 2008;11: Nr 6

57. Target international normalized ratio (INR) for
mechanical prostheses

58. • The risk of major bleeding increases considerably when the INR
exceeds 4.5 and increases exponentially above an INR of 6.0.
• An INR ≥6.0 therefore requires rapid reversal of anticoagulation
because of the risk of subsequent bleeding.
• In the absence of bleeding, the management depends on the target
INR, the actual INR, and the half-life of the vitamin K antagonist
used. It is possible to stop oral anticoagulation and to allow the INR
to fall gradually or to give oral vitamin K in increments of 1or 2 mg.
• If INR 10higher doses of oral vitamin K (5 mg).
The oral route the intravenous route
• If severe bleeding: Immediate reversal of anticoagulation
Intravenous +prothrombin complex concentrate +oral vitamin K,
whatever the INR.