Complicated type B aortic dissection should not be treated with uncovered stents: a lesson not yet learned.

Whenever some basic rules for endovascular aortic repair of type B aortic dissection are not followed, iatrogenic complications may develop. A 64-year-old gentleman was referred to our institution for revision of previous treatment of complex type B aortic dissection with 2 bare stents. At 3 months, the most proximal aortic bare stent had entered, via the proximal tear, the false lumen. Aortic expansion and dynamic obstruction at the level of the renal arteries had also developed. In a first step, we removed the proximal aortic bare stent surgically. Few days later, 2 covered endografts were implanted into the true lumen of the thoracic aorta with clinical success. The rationale for using endovascular treatment in patients with complicated type B aortic dissection is coverage of the entry tear with covered nonoversized endografts. Negative results are achieved whenever these very simple rules are not strictly followed.

Challenges in patient selection for the parachute device implantation.

BACKGROUND: A novel percutaneous ventricular restoration therapy (PVRT) has been recently proposed to treat patients with ischemic heart failure (IHF) and antero-apical regional wall motion abnormalities after myocardial infarction (MI). In this prospective, single center, non-randomized study, we herein propose safety and feasibility evaluation of the device, in which a different patient selection strategy was used. MATERIAL AND METHODS: A three-stage evaluation was adopted in a series of patients referred for a Parachute Ventricular Partitioning Device (Parachute™). After an initial clinical evaluation, a secondary screening step was performed according to echocardiographic functional (LVEF<40%, apical/anterior akinesia/dyskinesia) and anatomical criteria [diameter of LV-apex (LVAD) = 4.0 × 5.0 cm, left ventricular end diastolic diameter (LVEDD)>56 mm, left ventricular end systolic diameter (LVESD)>38 mm]. Patients encountering the echocardiographic criteria were selected for 3D cardiac CT (architecture, geometry, and trabeculation of the left ventricle) and eventually treated with the Parachute™. RESULTS: Fifty patients were screened according to the echocardiographic criteria. Twenty-seven of those that met the echo inclusion criteria underwent further cardiac CT imaging. After CT imaging, eight patients were scheduled for Parachute™ implantation. The device was successfully implanted in all eight patients with no in-hospital mortality. A 3-month follow-up echocardiography showed LV-volume reduction [95% CI; LVEDV: -76.5 (-116; -36.8), P = 0.002 and LVESV: -47.4 (-63.8; -30.9), P = 0.003] and improvement of global EF [95% CI; global EF: 6.87 (5.36; 8.39), P = 0.008]. CONCLUSION: Selection criteria for Parachute™ placement should include left ventricular functional and anatomical parameters. When preprocedural echocardiography and cardiac CT are adequately implemented, satisfactory periprocedural and short term follow-up results may be achieved after Parachute™ implantation.

Parachute implant: CT morphological criteria of our center to identify the suitable patient.

AIMS: In this study, we present and discuss our institutionalized and standardized computed tomography (CT) morphological criteria for the treatment of patients with a parachute device. METHODS AND RESULTS: After clinical and echocardiographic screening of 79 patients with ischemic heart failure, 28 were examined using multidetector computed tomography (MDCT) to assess their suitability for treatment with a parachute implant. From the 28 examined patients, nine were suitable for parachute implantation. Within the group of excluded patients, the cardiac diameters of one-third of the patients were too large, whereas for another third they were too small. Approximately 20% of the patients were rejected because of a deep insertion of the papillary muscles. Further reasons included left ventricular bands as well as mismatches between CT and echocardiographic measurements of left ventricular ejection fraction (LVEF). CONCLUSIONS: To ensure a safe parachute device implantation in patients with ischemic heart failure, only the CT at present offers the capability to obtain complete and dynamic three-dimensional (3D) measurements of the cardiac dimensions.

Asymptomatic blood cyst of the papillary muscle in an adult undergoing coronary bypass surgery.

Blood-filled cysts of larger size attached to the heart valves represent a very rare finding in adults. We report here a case of a blood-filled cyst attached to the papillary muscle, demonstrating the importance of multimodal preoperative diagnostic imaging combining both echocardiography and magnetic resonance imaging.