1046 Prognostic value of cardiac magnetic resonance imaging in mitral valve prolapse

Background Mitral valve prolapse (MVP) is a frequent pathology that can be complicated by mitral regurgitation, heart failure, rhythm disorders, arterial embolism and death. The aim of this study was to evaluate the prognostic interest of ventricular volumes, right ventricular ejection fraction (RVEF) and late gadolinium enhancement (LGE) assessed by cardiac magnetic resonance (CMR) imaging on cardiovascular morbi-mortality in a cohort of patients with MVP

Methods We examined the prognostic value of CMR imaging in 237 patients with MVP (no to severe mitral regurgitation) included between 2010 and 2019. All patients underwent a comprehensive echocardiography. The main endpoint was a composite endpoint of cardiovascular death, heart failure, new onset atrial fibrillation, arterial embolism.

Results Among the 237 patients (63% male), 97 (41%) had LGE (75 myocardial wall, 10 papillary muscle tip and 12 both locations). Factors associated with LGE in multivariable analysis were age (OR 1.02, P = 0.037), left ventricular (LV) mass (OR 1.01, P = 0.008) and pulmonary artery systolic pressure (PAPS, OR 1.02, P = 0.069). Follow-up was censored at the time of surgery or percutaneous repair. In univariate analysis NYHA class, LV mass, left atrial volume, PAPS, LV end-diastolic and end-systolic volumes, chordal rupture and MR degree were associated with outcome. RVEF and biventricular dysfunction (LV EF < 60% and RV EF < 40%) were also associated with impaired event-free survival (36.0 ± 17.0% vs 65.4± 5.8%, P = 0.019). Finally, LGE was associated with a decreased event-free survival (55.6 ± 9.9% vs 70.7± 6.9%, P = 0.002). In multivariablee analysis, moderate to severe mitral regurgitation (HR : 2.14 [1.44-3.19], P < 0.0001) and the presence of LGE were predictors of impaired event-free survival (HR : 2.12 [1.08-4.16], P = 0.003).

Conclusion CMR imaging provides additional prognostic information to echocardiography in the study of MVP. Myocardial fibrosis of the left ventricle and right ventricular function as assessed by CMR imaging are predictors of cardiovascular morbidity and mortality in MVP.

Late Failing Heart Allografts: Pathology of Cardiac Allograft Vasculopathy and Association With Antibody-Mediated Rejection

In heart transplantation, there is a lack of robust evidence of the specific causes of late allograft failure. We hypothesized that a substantial fraction of failing heart allografts may be associated with antibody-mediated injury and immune-mediated coronary arteriosclerosis. We included all patients undergoing a retransplantation for late terminal heart allograft failure in three referral centers. We performed an integrative strategy of heart allograft phenotyping by assessing the heart vascular tree including histopathology and immunohistochemistry together with circulating donor-specific antibodies. The main analysis included 40 explanted heart allografts patients and 402 endomyocardial biopsies performed before allograft loss. Overall, antibody-mediated rejection was observed in 19 (47.5%) failing heart allografts including 16 patients (40%) in whom unrecognized previous episodes of subclinical antibody-mediated rejection occurred 4.5 ± 3.5 years before allograft loss. Explanted allografts with evidence of antibody-mediated rejection demonstrated higher endothelitis and microvascular inflammation scores (0.89 ± 0.26 and 2.25 ± 0.28, respectively) compared with explanted allografts without antibody-mediated rejection (0.42 ± 0.11 and 0.36 ± 0.09, p = 0.046 and p < 0.0001, respectively). Antibody-mediated injury was observed in 62.1% of failing allografts with pure coronary arteriosclerosis and mixed (arteriosclerosis and atherosclerosis) pattern, while it was not observed in patients with pure coronary atherosclerosis (p = 0.0076). We demonstrate that antibody-mediated rejection is operating in a substantial fraction of failing heart allografts and is associated with severe coronary arteriosclerosis. Unrecognized subclinical antibody-mediated rejection episodes may be observed years before allograft failure.

Inflammatory cell burden and phenotype in endomyocardial biopsies with antibody-mediated rejection (AMR): a multicenter pilot study from the AECVP

This multicenter case-controlled pilot study evaluated myocardial inflammatory burden (IB) and phenotype in endomyocardial biopsies (EMBs) with and without pathologic antibody-mediated rejection (pAMR). Sixty-five EMBs from five European heart transplant centers were centrally reviewed as positive (grade 2, n = 28), suspicious (grade 1, n = 7) or negative (n = 30) for pAMR. Absolute counts of total, intravascular (IV) and extravascular (EV) immunophenotyped mononuclear cells were correlated with pAMR grade, capillary C4d deposition, donor specific antibody (DSA) status and acute cellular rejection (ACR). In pAMR+ biopsies, equivalent number of IV CD3+ T lymphocytes (23 ± 4/0.225 mm(2) ) and CD68+ macrophages (21 ± 4/0.225 mm(2) ) were seen. IB and cell phenotype correlated with pAMR grade, C4d positivity and DSA positivity (p < 0.0001). High numbers of IV T lymphocytes were associated with low grade ACR (p = 0.002). In late-occurring AMR EV plasma cells occurring in 34% of pAMR+ EMBs were associated with higher IB. The IB in AMR correlated with pAMR+, C4d positivity and DSA positivity. In pAMR+ equivalent numbers of IV T lymphocytes and macrophages were found. The presence of plasma cells was associated with a higher IB and occurrence of pAMR late after transplantation.

[Creation of software to help cardiac surgeons: CordaBase]

BACKGROUND

The writing of surgical and hospitalization reports is time-consuming and does not necessarily enable the increment of a statistical database, tool that is indispensable nowadays to evaluate unit activity or to carry out scientific studies. In order to prevent this double data capture, a computer tool, named CordaBase, has been developed by surgeons and set up in a cardiac surgery unit.

MATERIALS AND METHODS

CordaBase is an interactive software that stores medical data. Thanks to its intuitive interface, CordaBase stores data which is classified chronologically in the following categories: past medical history, preoperative assessment, operating gesture, stay in intensive care unit, stay in wards and evolution/monitoring after discharge. This date, stored in an Access base, are then used in the creation of personalized surgical and hospitalization reports. All the data is permanently available and can be used for the carrying out of scientific works or for the evaluation of the unit activity.

RESULTS

From March 2009 to December 2010, 2617 consecutive patients operated on in a Cardiac Surgery Unit were recorded prospectively in the software. All of this stored data assisted the surgeon in his or her administrative tasks, thanks to personalized surgical and hospitalization reports, immediately at the secretariat's disposal. The database, which is requisitely filled by administrative work, enables the carrying out of any statistical study on all unit activity.

CONCLUSION

With a hindsight of almost 2 years, CordaBase has proven its usefulness in an active cardiac surgery unit, both on an administrative and scientific level. The computerized reports have lightened the medical secretariat's workload and statistical studies have now become possible without having to take the paper medical files out again. In the years to come, the accumulation of medical data prospectively or retrospectively stored will surely confirm the potential of the use of such a software.

[A rare cause of myocardial infarction: papillary fibroelastoma of the aortic valve]

Papillary fibroelastoma is a rare, benign endocardial tumour usually located on the cardiac valves. Before echocardiography, these tumours were chance findings either at surgery or at autopsy. With the advent of echocardiography, the diagnosis has become commoner and they are often the cause of systemic embolism justifying surgical ablation. In this case, an aortic valve papillary fibroelastoma presented with myocardial infarction in a 78 year old woman with normal coronary angiography. The diagnosis was strongly suspected at echocardiography and confirmed by histological analysis of the surgically excised tumour.