[Complete atrioventricular block following long term treatment with chloroquine]. / Bloc auriculo-ventriculaire complet après prise de chloroquine au long cours.

Antimalarial agents are routinely used in the management of connective tissues diseases and various skin disorders. Ophthalmologic, neurological and digestive side effects of antimalarial agents are well known. However, cardiac toxicity is uncommon. We report a 49-year-old patient, treated with chloroquine for 21 years for a systemic lupus erythematosus and a discoid lupus, who presented a complete atrioventricular block that required implantation of a cardiac pacemaker in emergency. This patient did not have significant cardiovascular past medical history. Investigations excluded known causes of atrioventricular block and chloroquine toxicity was diagnosed. This case report illustrates the cardiotoxicity of synthetic antimalarial agents. A regular cardiovascular monitoring (especially with electrocardiogram) could be useful in patients receiving long-term treatment with antimalarial agents.

[Comparative study of exercise-induced ischaemia in coronaropathy and aortic stenosis]. / Etude comparative de l'ischémie d'effort entre patients coronariens et patients atteints de rétrécissement aortique.

OBJECTIVE: To compare exercise and recovery data between a population of patients with proven CAD and patients with pure aortic stenosis (AS). PATIENTS AND METHODS: Exercise testing results (bicycle ergometry) of 45 patients with AS (34 men, 66+/-12 years, 56+/-20 mmHg peak-to-peak gradient and valve area 0.78+/-0.48cm2) were compared to exercise testing results of 50 patients with CAD (41 men, 65+/-9 years, greater or equal to 70% stenosis on one vessel in 62%, two vessels in 30%, three vessels in 8%). RESULTS: During exercise, 38% patients with AS and 82% patients with CAD had clinical symptoms. In the AS group, exercise duration was longer, heart rate (HR) was higher, maximal systolic and diastolic blood pressure were lower than in CAD group. The increase of systolic blood pressure was lower in the AS group (34+/-21 mmHg versus 47+/-27 mmHg, p<0.02). Maximal load achieved was not significantly different. Exercise ST depression appeared in 76% of AS group and 88% of CAD group (NS). No difference was found in ST depression, Detrano index and ST segment/HR slope. During recovery, no difference was found in HR variations. Clockwise rotation of the ST/HR recovery loop was more frequent in CAD group (35 patients versus 19 patients, p<0.001). CONCLUSION: Most of the exercise and recovery data are similar in patients with AS and CAD. Significant discriminating criteria were the increase of systolic blood pressure during exercise and ST/HR recovery loop.

[Cardiomyopathy of the right ventricle revealed by pulmonary embolism]. / Cardiomyopathie du ventricule droit révélée par une embolie pulmonaire.

The authors report a case of cardiomyopathy of the right ventricle revealed suddenly in a presentation of pulmonary embolism in relation to a large thrombus that developed in an enormous, extremely hypokinetic right ventricle. The scenario suggests dysplasia without rhythm disorder. This case allows a discussion on the multiple variants of arhythmogenic dysplasia of the right ventricle.

[Exercise test in athletes]. / Epreuves d'effort chez les sportifs.

The particularities of exercise tests in athletes concern mainly the exertion protocols adapted to their increased physical capacities and the interpretation of ECG tracing which can sometimes be very special at rest and also misleading during exercise. In the great majority of cases, the test used is both cardiac and pulmonary, in order to assess the aerobic capacities, the maximal aerobic power, and the determination of ventilation thresholds (programming and follow-up of training...). More infrequently, the test is used to detect cardiovascular diseases, especially during a longitudinal follow-up of high-level athletes, or to exclude it in case of cardiovascular symptoms, atypical resting ECG or even in case of suspicion of disease (arrhythmia, cardiac chamber hypertrophy or dilation at echocardiography). In more aged sportsmen (athletes masters), exercise tests performed are usually required for screening coronary heart disease. In this case the test protocols should be more adapted for screening than for the assessment of sportive capacities.

[Thrombosis of valvular prostheses: the role of medical treatment]. / Thrombose de prothèses valvulaires: place du traitement médical.

Thromboses of valvular prostheses represent a rare but serious complication for mechanical valves, and are sometimes fatal. Obstructive thromboses present an immediate threat to life, while the more common, more insidious, non-obstructive thromboses are essentially manifested by thrombo-embolic events. These thromboses often occur at times of insufficient anticoagulation, especially during the first post-operative year and during treatment breaks for non-cardiac surgery, an increasingly common situation. The therapeutic management of an 'obstructive' thrombosis is above all surgical. However, fibrinolysis represents an effective alternative, although it does present a not insignificant risk of systemic embolism (in the order of 10 to 15%). The main indications for fibrinolysis are thromboses of right heart valves, and for left heart prostheses, patients in a very unstable haemodynamic state, remoteness from a cardiac surgery centre, any surgical contraindications, and cases where a large thrombus has been excluded by trans-oesophageal ultrasound. In cases of contraindications to both surgery and fibrinolysis, treatment with heparin might be proposed, but without any great hopes of completely unblocking the prosthesis. Treatment of a 'non-obstructive' thrombosis is primarily medical: optimising anticoagulation with intravenous heparin, or even the addition of aspirin. When the thrombus is large and mobile, surgery should be envisaged if medical treatment fails.

[Identification of candidates for multisite pacing: results and presumed mechanisms of action after five years experience]. / Identification des patients candidats a la stimulation multisite. Résultats et mécanismes d'action supposés a l'issue d'une expérience monocentrique de 5 ans.

Biventricular resynchronisation is an additional therapeutic option in the management of refractory heart failure, with a functional and haemodynamic benefit as well as an improved morbidity and mortality. However, the rate of non-responsive patients has prompted a re-think about the presumed mechanisms of action for this procedure. This study aims to identify candidates more successfully. Based on five years experience in this centre, our work confirmed a medium and long term clinical benefit with multisite pacing. Nevertheless, there was evidence of a relative discordance between the functional benefit and the haemodynamic impact in terms of ejection fraction achieved with resynchronisation. While QRS narrowing appears to be a predictive factor for a successful procedure, the ECG alone is not sufficient to select 'unsynchronised' candidates. Statistical analysis reveals that before implantation the independent predictive factors to identify non-responsive patients include the presence of a complication of myocardial infarction and a low grade mitral leak. The limits of the ECG suggest a more mechanical than electrical approach to understanding the mechanisms of action for resynchronisation. Its effectiveness in cases of right bundle branch block confirm the hypothesis of left intra-ventricular conduction defects, not apparent on the surface ECG but accessible through new imaging techniques. Based on the hypothesis of delayed movement of the ventricular walls, the principle of resynchronisation aims to restore homogenous contraction. Echocardiography allows observation of electromechanical delay and opens new perspectives in the future for selecting patients for pacing. Ar

Heart failure with preserved systolic function: a diagnostic algorithm for a pragmatic definition.

Heart failure is a major health problem which often concerns the elderly. Prevalence of heart failure with preserved systolic function is increasing and varies from 40 to 50%. In the literature, and in the large epidemiological studies, it is commonly designed with the term of "diastolic heart failure", even if a precise analysis of diastolic function is not performed. A diagnostic algorithm is proposed in order to better define the concept of heart failure with preserved systolic function. It consists of seven steps from symptoms and clinical signs to the echocardiographic analysis of diastolic function, in order to confirm the definition of heart failure with preserved systolic function.

Electrophysiological end point for catheter ablation of atrial fibrillation initiated from multiple pulmonary venous foci.

BACKGROUND: The end point for catheter ablation of pulmonary vein (PV) foci initiating atrial fibrillation (AF) has not been determined. METHODS AND RESULTS: Ninety patients underwent mapping during spontaneous or induced ectopy and/or AF initiation. Ostial PV ablation was performed by use of angiograms to precisely define targeted sites. Success defined by elimination of AF without drugs was correlated with the procedural end point of the abolition of distal PV potentials. A total of 197 arrhythmogenic PV foci (97%)-single in 31% and multiple in 69%-and 6 atrial foci were identified. A discrete radiofrequency (RF) application eliminated the PV potentials in 9 PV foci, whereas 2 foci from the same PV required RF applications at separate sites in 19 cases. In others, a wider region was targeted with progressive elimination of ectopy. In 49 patients, multiple sessions were necessary owing to recurrent or new ectopy. The clinical success rates were 93%, 73%, and 55% in patients with 1, 2, and > or =3 arrhythmogenic PV foci. Recovery of local PV potential and the inability to abolish it were significantly associated with AF recurrences (90% success rate with versus 55% without PV potential abolition). PV stenosis was noted acutely in 5 of 6 cases, remained unchanged at restudy, and was associated with RF power >45 W. CONCLUSIONS: Multiple PV foci are involved in initiation of AF, and elimination of PV muscle conduction is associated with clinical success.

Early and long-term (one-year) effects of the association of aspirin and oral anticoagulant on thrombi and morbidity after replacement of the mitral valve with the St. Jude medical prosthesis: a clinical and transesophageal echocardiographic study.

OBJECTIVES: The aim of the study was to test the value of low dose aspirin associated with standard oral anticoagulants (OAC) after mechanical mitral valve replacement (MMRV) to reduce strands, thrombi and thromboembolic events. BACKGROUND: Strands and thrombi are thought to increase the risk of embolic events after MMVR, particularly in the immediate postoperative period. METHODS: Two hundred twenty-nine patients were prospectively recruited: 109 patients (group A+) were randomly assigned to aspirin (200 mg per day) with OAC and 120 patients (group A-) to OAC alone (international normalized ratio 2.5 to 3.5). All patients were subjected to multiplane transesophageal echocardiography at nine days and five months and were followed up for one year. RESULTS: At nine days and five months, there was a high and comparable incidence of strands in the two groups (group A+: 44%, 58%; group A-: 49%, 63%). However, the incidence of nonobstructive periprosthetic valve thrombi was significantly lower in group A+ at 9 days: 5% versus 13%, p = 0.03. Total thromboembolic events were reduced in group A+ (9% vs. 25%, p = 0.004) although there was an increased incidence of gastrointestinal hemorrhage (7% vs. 0%). Overall mortality was 9% in group A+ and 4% in group A-. Valve-related events were similar in both groups. Early thrombi, but not strands, were associated with higher morbidity, especially thromboembolic events (30% vs. 13%, p = 0.003). CONCLUSIONS: One year after MMVR, the association of aspirin with OAC reduced thrombi and thromboembolic events, but not morbidity, due to an increase in hemorrhagic complications.

Acute thrombotic obstruction with disc valve prostheses: diagnostic considerations and fibrinolytic treatment.

Twenty-six patients presenting with 28 instances of massive acute thrombotic obstruction of a prosthetic valve (16 mitral, 12 aortic) were treated with fibrinolytic agents. In 15 cases the patient presented with acute pulmonary edema and low cardiac output, in 10 with congestive heart failure and embolism and in 3 with peripheral embolism only. The diagnosis of thrombotic obstruction was made by echocardiography or cineradiography, in patients in whom the disc was immobile or barely moving; cineangiography was necessary in only four patients. The fibrinolytic agents administered were streptokinase, 2,000,000 U for 10 hours (14 cases), urokinase, 4,500 U/kg per h for 12 hours (7 cases), or the two agents successively (7 cases). Fibrinolysis was entirely successful in 19 patients: 18 are alive and well without surgical intervention after follow-up of 6 to 64 months and 1 patient had surgical revision after fibrinolysis. In two patients, fibrinolytic treatment was apparently successful but obstruction recurred 4 and 19 months later, respectively, and the patients were again treated by fibrinolysis. In two patients complete failure of fibrinolytic treatment led to emergency surgery, and in three patients improvement was incomplete and death occurred shortly after treatment. No hemorrhagic complications were observed, but there were five cases of embolism during the fibrinolytic treatment. Fibrinolytic treatment would seem to be an attractive, nonsurgical alternative for the thrombosis of a valve prosthesis but, because of the risk of embolism with possible permanent damage, its use should be reserved for critically ill patients who are too sick to undergo immediate surgery.

Guidelines for management of left-sided prosthetic valve thrombosis: a role for thrombolytic therapy. Consensus Conference on Prosthetic Valve Thrombosis.

OBJECTIVES: We sought to form a consensus recommendation for management of prosthetic valve thrombosis (PVT) from previous case and uncontrolled reports from a consensus of international specialists. BACKGROUND: PVT and thromboembolism relate to inadequate anticoagulation and valve type and location. PVT is suspected by history (dyspnea) and auscultation (muffled valve sounds or new murmurs) and confirmed by Doppler echocardiography showing a marked valve gradient. METHODS: A consensus conference was held to recommend management of left-sided PVT. RESULTS: Transesophageal Doppler echocardiography is used to visualize abnormal leaflet motion and the size, location and mobility of thrombus. Thrombolysis is used for high risk surgical candidates with left-sided PVT (New York Heart Association functional class III or IV) because cerebral thromboembolism may occur in 12% of patients. Duration of thrombolysis depends on resolution of pressure gradients and valve areas to near normal by Doppler echocardiography performed every few hours. Lysis is stopped after 72 or 24 h if there is no hemodynamic improvement (operation indicated). Heparin infusion with frequent measurement of activated partial thromboplastin time (aPTT) begins when aPTT is more than twice control levels and can be converted to warfarin (international normalized ratio [INR] 2.5 to 3.5) plus aspirin (81 to 100 mg/day). Patients in functional class I or II have lower surgical mortality, and those with large immobile thrombi on the prosthetic valve or left atrium have responded to endogenous lysis with combined subcutaneous heparin every 12 h (aPTT 55 to 80 s) plus warfarin (INR 2.5 to 3.5) for 1 to 6 months. Operation is advised for nonresponders or patients with mobile thrombi. CONCLUSIONS: Thrombolysis, followed by heparin, warfarin and aspirin, is advised for high risk surgical candidates with left-sided PVT.

[Myocardial perfusion and contrast echocardiography. Application to acute coronary syndrome]. / Perfusion myocardique et échocardiographie de contraste. Application au syndrome coronaire aigu.

After mastering epicardial revascularisation, the therapeutic management of acute coronary syndrome has progressively turned towards the preservation of the capillary microcirculation. In this respect, contrast echocardiography provides all the answers to the main questions which arise, and is available within a timeframe and place compatible with the management of such patients. The techniques for microbubble detection, quantification tools, and contrast agents are well optimised for routine use both for initial diagnosis as well as monitoring the therapeutic effectiveness. It is only the administrative authorisation which is currently lacking treatment.

[Echocardiography and biventricular resynchronisation]. / Echocardiographie et resynchronisation biventriculaire.

Biventricular resynchronisation has been recently shown to be an effective therapeutic option in patients with refractory dilated cardiomyopathy. Based on the finding of ventricular asynchrony, the aim of the method is to restore uniform contraction of the ventricular walls. However, the initial electrocardiographic criteria for selection of patients were only associated with a 70% rate of response. Consequently, it became necessary to refocus this method in patients with true ventricular asynchrony. Echocardiography is one of the non-invasive techniques which provides morphological and functional analysis of the myocardium with a high degree of accessibility. The multiplication of tools for echocardiographic quantification has been very valuable from a theoretical point of view for assessing ventricular asynchrony. In practice, techniques such as Doppler tissue imaging are being validated, but already offer the possibility of a multi-directional approach to this pathology. The diagnosis of asynchrony is based on a range of echocardiographic findings which not only improve the selection of patients but also optimise the programming of multisite stimulation.

[Diagnosis difficulty in occult constrictive pericarditis]. / Difficulté diagnostique de la péricardite constrictive occulte. A propos d'un cas.

We report the case of a 42 years woman known to have a cardiac heart failure attributed to restrictive cardiomyopathy for want of any other plausible diagnosis. Evolution and repeted investigations finally permitted to rectify the diagnosis by revealing a constrictive pericarditis, remained occult 9 years during. The differentiation of restrictive cardiomyopathy and constrictive pericarditis has been a perennial problem in clinical cardiology. Diagnosis of constrictive pericarditis is based on associated signs sometimes too poor to go straight to thoracotomy. We discuss the mean to approach more precisely this uncommon pattern named occult constrictive pericarditis.

[Asynchronism and right ventricular pacing]. / Asynchronisme et stimulation ventriculaire droite. Démonstration de l'effet délétère d'une stimulation apicale dans une population d'adultes appareillés pour BAV congénital.

UNLABELLED: In patients with congenital heart block (CHB), dual-chamber pacing restores physiological heart rate and atrio-ventricular synchronization. However, patients with narrow QRS junctional escape rhythm may be deleteriously affected by long-term, permanent, apical ventricular pacing. We assessed the impact of apical ventricular pacing on echocardiographic ventricular dyssynchrony and hemodynamic parameters. METHODS: Fourteen CHB adults (23 +/- years, 58% male), with a DDD transvenous pacemaker and a junctional escape rhythm (QRS<120 ms) before implantation, were studied. Echocardiography coupled with tissue Doppler imaging (TDI) and Strain rate was performed in spontaneous rhythm (VVI mode 30/mn) and during atrio-synchronized ventricular pacing. RESULTS: The heart rate (43 +/- 09 vs 68 +/- 07: p<0.01), cardiac output (2.9 +/- 0.7 vs 3.7 +/- 0.6 L/min) and left ventricular filling time (325 +/- 38 vs 412 +/- 51 ms; p<0.01) were significantly less in the escape spontaneous rhythm compared with atrio-ventricular synchronized apical pacing. However, interventricular dyssynchrony (28 +/- 12 vs 59 +/- 25 ms, p<0.05), intra-left ventricular dyssynchrony (36 +/- 11 vs 57 +/- 29 ms; p<0.05), extent of left ventricular myocardium displaying delayed longitudinal contraction (26 +/- 10 vs 39 +/- 17%: p<0.05) were significantly less in the escape rhythm compared with paced rhythm. CONCLUSION: Once implanted with a DDD pacemaker, CHB patients present with increased cardiac output secondary to the restoration of physiological heart rate and improved diastolic function. However, the apical site is not optimal, as it creates detrimental ventricular dyssynchrony in patients with previous nearly physiological ventricular activation. Alternative pacing sites should be investigated.

[Severity of aortic ring abscess complicated by cardiac conduction abnormalities]. / Sévérité des endocardites abcédées du manchon aortique compliquées d'anomalies de la conduction.

OBJECTIVE: To determine clinical features, management and prognosis of cardiac conduction abnormalities (CCA) complicating abscessed endocarditis. METHODS: We have analysed clinical, microbiologic and echocardiographic datas, therapies and outcome of cardiac abscesses complicated by CCA in patient hospitalized between 1995 and 2001 in our centre. RESULTS: Above 35 cardiac abscesses, six men (mean age 62 years) had CCA complicating six aortic ring abscesses (4 on native valve and 2 on prosthetic valve) with four cases of interventricular septal involvement and fistulization. Severe heart failure is present four times, a septic cerebral embolization twice. Streptococcus and Staphylococcus prevail. Complete atrioventricular block (AVB) reveals endocarditis twice and complicates the evolution three times. Trifascicular block (first degree AVB, left anterior fascicular block and complete right bundle branch block) revealed recurrence of endocarditis. Two patients were treated medically: one died quickly (complete AVB pre-mortem), and the other one had favourable issue (paroxystic complete AVB). Four patients had surgery with temporary pacemaker in three cases (one died) then definitive pacemaker in two cases. At 26.5 month (7-50), the four survivors had no recurrence of endocarditis. CONCLUSION: Severe CCA are classical in aortic ring abscessed endocarditis and associated with increased mortality. Immediate transfert in a dentre with cardiac surgery is necessary. Definitive cardiac pacing can be performed early without leads infection.

Ramipril-induced regression of left ventricular hypertrophy in treated hypertensive individuals. HYCAR Study Group.

The objective of this trial was to assess the effects of 6-month daily treatment with two doses of ramipril on left ventricular mass and the dependence of this on blood pressure changes in hypertensive patients with left ventricular hypertrophy. After a selection phase of 4 to 6 weeks with patients under antihypertensive therapy with 20 mg furosemide daily, 115 patients with either controlled or uncontrolled hypertension and left ventricular hypertrophy were randomized in a double-blind manner to receive either placebo (n = 40), 1.25 mg (low dose, n = 38), or 5 mg (regular dose, n = 37) ramipril daily for 6 months. Treatment with furosemide was continued unchanged during this phase. The main outcome measured was left ventricular hypertrophy regression as assessed from central blind reading of echocardiograms recorded at randomization and after 6 months. No significant differences were observed for changes in casual or ambulatory blood pressure between the three groups. Left ventricular mass index was found to be significantly reduced in patients receiving 5 mg ramipril compared with those receiving placebo (-10.8 +/- 3.7 versus +4.1 +/- 4.0 g/m2, P = .008); in patients receiving 1.25 mg ramipril, the difference was close to borderline significance compared with placebo (-7.0 +/- 4.3 g/m2, P = .06). Similar results were observed for changes in left ventricular mass (-20.3 +/- 6.6 and -13.0 +/- 7.8 g in the 5- and 1.25-mg ramipril groups, respectively, versus +9.1 +/- 7.2 g in the placebo group; P = .004 and .04, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Short- and long-term treatment of mild to moderate hypertension with verapamil.

Forty-three patients with mild to moderate hypertension (supine diastolic blood pressure 95 to 115 mm Hg) were entered into a short-term (3 months) study. All received verapamil, 120 mg 3 times a day. After 1 month of treatment on verapamil alone, supine diastolic blood pressure was normalized (less than 95 mm Hg) in 29 patients (67%). These patients continued with verapamil at the same dosage. In 14 nonresponders (supine diastolic blood pressure greater than 95 mm Hg) a combination of althiazide (15 mg/day) and spironolactone (25 mg/day) was added. This resulted in diastolic blood pressure normalization in 9 additional patients. Verapamil induced a slight but moderate decrease in heart rate after 1 month, but no further decrease was observed thereafter. During the trial, 21% of patients reported adverse effects, mostly transient and mild. No patient had to discontinue treatment because of them. Twenty-six patients on verapamil alone were followed for 1 year. Systolic and diastolic blood pressure was adequately controlled in all patients except 1. In 13 the dosage was decreased to 120 mg 2 times a day. There were no significant differences in blood pressure between this group and patients given 120 mg 3 times a day. It is concluded that verapamil is an effective and safe antihypertensive agent in mildly to moderately hypertensive patients. Because a dosage of 120 mg 2 times a day was as effective as 120 mg 3 times a day, the former should be recommended, as it may improve patient compliance.

Improved reliability for echocardiographic measurement of left ventricular volume using harmonic power imaging mode combined with contrast agent.

Harmonic power imaging (HPI) is a new echocardiographic modality that enhances the detection of contrast agents in the left ventricle. The endocardium can be delineated by conventional echocardiography using ultrasound contrast agents, although the images tend to be faint. The present study was designed to assess left ventricular volume using HPI after intravenous injection of the contrast agent Levovist (Schering SA, Berlin, Germany) in 25 unselected patients. End-diastolic volume, end-systolic volume, and ejection fraction were determined for each patient with angiography and with 4 different ultrasound modalities: (1) conventional mode without contrast, (2) contrast conventional mode, (3) contrast harmonic intermittent imaging mode, and (4) contrast triggered HPI. The use of HPI improved correlations between the echographic and angiographic measurements for all parameters as well as precision and bias determined by Bland and Altman analysis. The relative errors for interobserver variability were also lower with HPI. This study demonstrates that echocardiographic determination of left ventricular volumes and ejection fraction is more accurate and reproducible using HPI combined with Levovist.

Value of transesophageal echocardiography combined with computed tomography for assessing repaired type A aortic dissection.

Thirty-two patients with repaired type A aortic dissection were examined by transthoracic echocardiography (TTE) (n = 32), transesophageal echocardiography (TEE) (n = 30), computed tomography (CT) (n = 29), or a combination of all 3, to assess course and complications as a function of the surgical procedure. The mean follow-up period was 55.7 months (range 3 to 132). Surgery consisted of a replacement of the ascending aorta in 25 patients (group 1) with extension to the transverse aorta in 7 (group 2). The transverse diameter of the aorta, the persistence of the false lumen, thrombus formation and flow dynamics in the false lumen were evaluated by TEE. Ten patients (31%) had a dilation in the initial ascending aorta (sinus of Valsalva aneurysm in 6 patients, and a false aneurysm in the other 4). Three of 4 patients with a proximal pseudoaneurysm underwent operation after TEE and CT evaluation. In the descending thoracic aorta, there was good agreement between TEE and CT scan determinations of transverse vessel diameter. Persistence of flow within the false lumen was significantly more frequent in patients with a dilated aorta (p < 0.05), whereas thrombosis was seen more often and false lumen less often in patients with nondilated aorta. No significant differences in vessel status or outcome were observed between the 2 groups, although this may have been due to the small size of group 2. TEE is thus a well-tolerated method for postoperative follow-up of type A aortic dissection whatever the type of surgery. For the upper ascending aorta, CT provided sufficient data.