Long-term results of surgical treatment of secondary severe mitral regurgitation in patients with end-stage heart failure: Advantage of prosthesis insertion.

BACKGROUND: Surgical treatment of secondary mitral regurgitation (SMR) is controversial. AIM: To analyse outcome after undersizing annuloplasty (UA) and mitral valve replacement (MVR). METHODS: Consecutive patients operated on for severe SMR, with left ventricular ejection fraction (LVEF)<40% and refractory CHF, were included. Endpoints were in-hospital mortality, mid-term cardiovascular (CV) mortality, evolution of LV variables and recurrence of mitral regurgitation (MR). RESULTS: 59 patients were included (mean age 65±10 years, preoperative LVEF 36±6%; effective regurgitant orifice [ERO] 41±17 mm2), 41 with ischaemic disease: 12 underwent UA and 47 underwent MVR; only eight had concomitant coronary revascularization. In-hospital mortality was 3.3% (8.3% in UA group; 2.1% in MVR group). Eight-year CV mortality was 39±13% (40±18% in UA group; 27±10% in MVR group). Older age (hazard ratio 1.14, 95% confidence interval 1.07 to 1.22; P<0.001) and LV end-systolic diameter (hazard ratio 1.18, 95% confidence interval 1.09 to 1.27; P<0.001) independently predicted CV mortality. LVEF did not change between the preoperative and follow-up transthoracic echocardiograms in the MVR group (36±6% vs. 35±10%; P=0.6) or the UA group (36±5% vs. 31±12%; P=0.09). Conversely, LV end-diastolic diameter decreased significantly in the MVR group (64±8m to 59±9mm; P=0.002), but not in the UA group (61±7m to 64±10mm; P=0.2). Recurrence of significant MR occurred in 81% of patients in the UA group (mean postoperative ERO 19±6 mm2) versus none in the MVR group. CONCLUSIONS: Surgical treatment of SMR can be performed with acceptable operative risk and mid-term survival in severe heart failure, even if there is no indication for revascularization. MVR is associated with significant reverse remodelling, and UA with prohibitive risk of MR recurrence.

Impact of Direct Transcatheter Aortic Valve Replacement Without Balloon Aortic Valvuloplasty on Procedural and Clinical Outcomes: Insights From the FRANCE TAVI Registry.

OBJECTIVES: This study sought to describe the current practices and compare outcomes according to the use of balloon aortic valvuloplasty (BAV) or not during transcatheter aortic valve replacement (TAVR). BACKGROUND: Since its development, aortic valve pre-dilatation has been an essential step of TAVR procedures. However, the feasibility of TAVR without systematic BAV has been described. METHODS: TAVR performed in 48 centers across France between January 2013 and December 2015 were prospectively included in the FRANCE TAVI (Registry of Aortic Valve Bioprostheses Established by Catheter) registry. We compared outcomes according to BAV during the TAVR procedure. RESULTS: A total of 5,784 patients have been included in our analysis, corresponding to 2,579 (44.6%) with BAV avoidance and 3,205 (55.4%) patients with BAV performed. We observed a progressive decline in the use of BAV over time (78% of procedures in 2013 and 49% in the last trimester of 2015). Avoidance of BAV was associated with similar device implantation success (97.3% vs. 97.6%; p = 0.40). TAVR procedures without BAV were quicker (fluoroscopy 17.2 ± 9.1 vs. 18.5 ± 8.8 min; p < 0.01) and used lower amounts of contrast (131.5 ± 61.6 vs. 141.6 ± 61.5; p < 0.01) and radiation (608.9 ± 576.3 vs. 667.0 ± 631.3; p < 0.01). The rates of moderate to severe aortic regurgitation were lower with avoidance of BAV (8.3% vs. 12.2%; p < 0.01) and tamponade rates (1.5% vs. 2.3%; p = 0.04). CONCLUSIONS: We confirmed that TAVR without BAV is frequently performed in France with good procedural results. This procedure is associated with procedural simplification and lower rates of residual aortic regurgitation.

Peri-operative oral caffeine does not prevent postoperative atrial fibrillation after heart valve surgery with cardiopulmonary bypass: A randomised controlled clinical trial.

BACKGROUND: Raised plasma levels of endogenous adenosine after cardiac surgery using cardiopulmonary bypass (CPB) have been related to the incidence of postoperative atrial fibrillation (POAF). OBJECTIVE: We wished to assess if caffeine, an adenosine receptor antagonist could have a beneficial effect on the incidence of POAF. DESIGN: A randomised controlled study. SETTING: Single University Hospital. PATIENTS: One hundred and ten patients scheduled for heart valve surgery with CPB. INTERVENTIONS: We randomly assigned patients to receive peri-operative oral caffeine (400 mg every 8 h for 2 days) or placebo. Adenosine plasma concentrations and caffeine pharmacokinetic profile were evaluated in a subgroup of 50 patients. MAIN OUTCOME MEASURES: The primary endpoint was the rate of atrial fibrillation during postoperative hospital stay. RESULTS: The current study was stopped for futility by the data monitoring board after an interim analysis. The incidence of atrial fibrillation was similar in the caffeine and in the placebo group during hospital stay (33 vs. 29%, P = 0.67) and the first 3 postoperative days (18 vs. 15%; P = 0.60). Basal and postoperative adenosine plasma levels were significantly associated with the primary outcome. Adenosine plasma levels were similar in the two treatment groups. Caffeine administration was associated with a higher incidence of postoperative nausea and vomiting (27 vs. 7%, P = 0.005). CONCLUSION: Oral caffeine does not prevent POAF after heart valve surgery with CPB but increased the incidence of postoperative nausea and vomiting. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, no.: NCT01999829.

Rapid-deployment aortic valve replacement for severe aortic stenosis: 1-year outcomes in 150 patients.

OBJECTIVES: This study aimed to evaluate the safety and effectiveness of rapid-deployment aortic valve replacement (RDAVR) for severe aortic stenosis (AS). METHODS: All consecutive patients with severe AS who underwent RDAVR with the EDWARDS INTUITY bioprosthesis were prospectively included in a single-centre, cohort study between July 2012 and April 2015. Clinical examination and transthoracic echocardiography were performed preoperatively and at 1-month and 1-year follow-up. RESULTS: We included 150 patients: mean age 76.8 ± 6.2 years, 68.7% male and mean EuroSCORE II 3.4 ± 3.7%. Implantation was successful in all: 103 (68.7%) had isolated aortic valve replacement (AVR) and 47 (31.3%) had concomitant procedures. For isolated AVR, mean cross-clamp and cardiopulmonary bypass times were 37.6 ± 13.3 and 59.9 ± 20.4 min, respectively. Overall, the 1-year Kaplan-Meier survival rate was 97.1% (95% confidence interval 92.4-98.9%). At 1 year, stroke occurred in 5 patients (3.34%), myocardial infarction in 1 (0.69%), endocarditis in 1 (0.69%), early explantation in 1 (0.67%), pacemaker implantation in 8 (5.6%) and Grade 2 periprosthetic regurgitation in 4 (3.2%; no grade 3 of 4). There were significant decreases from baseline ( P < 0.001) in the proportion at New York Heart Association Class III/V (35.3-4.1%), mean gradient (54.9 ± 17.3 mmHg to 11.3 ± 4.8 mmHg) and mean left ventricular mass index (160.3 ± 44.8 g/m 2 to 118.5 ± 39.4 g/m 2 ). Mean indexed effective orifice area at 1 year was 1.02 ± 0.37 cm 2 /m 2 . Ten patients (6.6%) had severe patient-prosthesis mismatch. CONCLUSIONS: RDAVR for severe AS provided favourable outcomes over 1 year.

Infective endocarditis in octogenarians.

OBJECTIVE: To describe the characteristics of infective endocarditis (IE) in octogenarians and assess their prognosis. METHODS: Patients with definite IE hospitalised at a referral centre between July 2008 and July 2013 were prospectively included. A total of 454 patients were divided into three groups: 230 patients under 65 years old, 173 patients between 65 and 80 years old, and 51 patients over 80 years old. The main end point was 1-year mortality. RESULTS: One-year mortality was higher in the ≥80 years old group (37.3%) than in the <65 years old group (13%; p<0.001) and the 65-80 years old group (19.7%; p=0.009). Enterococci and Streptococcus gallolyticus were the more frequent micro-organisms. Embolism under antibiotic therapy (n=11 (21.6%), p=0.03) and renal failure (n=23 (51%), p=0.004) were more frequent in the ≥80 years old group. Among the ≥80 years old group, 38 patients had theoretical indication for surgery. Mortality was low (6.3%) in the 16 operated patients, but very high (72.7%) in the 22 patients not operated. Even if octogenarians were less often operated, their survival after surgery was excellent like younger patients (93.7%, 89.9% and 90.4%, respectively), whereas the absence of surgery was associated with very poor prognosis. CONCLUSIONS: IE in octogenarians is a different disease, with Enterococci as the most frequent micro-organisms and with higher mortality than younger patients. ESC recommendations for surgery are less implemented than in younger patients, yielding dramatic mortality in patients not operated despite a theoretical indication for surgery, while operated patients have an excellent prognosis. These results suggest that surgery is underused in octogenarians.

Evaluation of empirical treatment for blood culture-negative endocarditis.

OBJECTIVES: Much progress has been made in understanding the main causes of blood culture-negative endocarditis (BCNE). Few studies concerning BCNE treatment (due to previous antibiotics used or fastidious pathogens) are available. We performed this study to evaluate the effectiveness of our therapeutic protocol in BCNE, based on compliance with the protocol, outcome and 1 year mortality. PATIENTS AND METHODS: We collected prospectively and analysed retrospectively cases of BCNE between 2002 and 2014, using a simplified and standardized protocol developed by our multidisciplinary team. We apply two kinds of protocols to treat BCNE, which include only four intravenous antimicrobial agents: amoxicillin, vancomycin, gentamicin and amphotericin B. RESULTS: We had 177 patients with definite BCNE. There were 154 (87.0%) patients treated with both appropriate antimicrobial agents and appropriate duration of treatment. We analysed the causes of inappropriate treatment in 13 (7.3%) cases and inappropriate duration in 10 (5.6%) cases. The treatment changes were justified in all cases except one of discharge against medical advice. The fatality rate was 5.1% (nine cases) and all deaths occurred in the group of patients who were treated with appropriate treatment; however, four deaths were not attributable to empirical treatment failure. Concerning the other deaths, the lack of surgical management, in association with empirical treatment, could explain our protocol's failure, such as poorly tolerated surgery. CONCLUSIONS: Our protocol is efficient and our mortality rate was low, compared with the literature review. This may result from a strategy that uses a sampling procedure and a standardized protocol at the same time.

Cross-Reactivity Between Heparin and Danaparoid Antibodies in Cardiac Surgery.

Management of heparin-induced thrombocytopenia (HIT) entails cessation of heparin and initiation of a nonheparin parenteral anticoagulant such as danaparoid. Danaparoid cross-reactivity with HIT antibodies is an uncommon complication of treatment of HIT. We report the case of confirmed HIT and in vivo cross-reactivity with danaparoid, complicating severe sepsis due to an infectious endocarditis treated by cardiac surgery.

Drug-induced aortic valve stenosis: An under recognized entity.

BACKGROUND: We have been intrigued by the observation that aortic stenosis (AS) may be associated with characteristic features of mitral drug-induced valvular heart disease (DI-VHD) in patients exposed to valvulopathic drugs, thus suggesting that beyond restrictive heart valve regurgitation, valvulopathic drugs may be involved in the pathogenesis of AS. METHODS: Herein are reported echocardiographic features, and pathological findings encountered in a series of patients suffering from both AS (mean gradient >15mmHg) and mitral DI-VHD after valvulopathic drugs exposure. History of rheumatic fever, chest radiation therapy, systemic disease or bicuspid aortic valve disease were exclusion criteria. RESULTS: Twenty-five (19 females, mean age 62years) patients having both AS and typical features of mitral DI-VHD were identified. Mean transaortic pressure gradient was 32+/-13mmHg. Aortic regurgitation was ≥ mild in 24 (96%) but trivial in one. Known history of aortic valve regurgitation following drug initiation prior the development of AS was previously diagnosed in 17 patients (68%). Six patients underwent aortic valve replacement and 3 both aortic and mitral valve replacement. In the 9 patients with pathology analysis, aortic valvular endocardium was markedly thickened by dense non-inflammatory fibrosis, a characteristic feature of DI-VHD. CONCLUSION: The association between AS and typical mitral DI-VHD after valvulopathic drug exposure may not be fortuitous. Aortic regurgitation was usually associated to AS and preceded AS in most cases but may be lacking. Pathology demonstrated the potential role of valvulopathic drugs in the development of AS.

Rapid Deployment of Aortic Bioprosthesis in Elderly Patients With Small Aortic Annulus.

BACKGROUND: Aortic valve replacement in elderly patients with a small aortic annulus remains challenging. Patient-prosthesis mismatch (PPM) should be prevented without impacting operative mortality. Hemodynamic benefits resulting from rapid-deployment aortic valve replacement with the Edwards Intuity bioprosthesis for this indication were evaluated. METHODS: Elective patients with severe aortic stenosis who required an Edwards Intuity bioprosthesis, size 19 mm and 21 mm, were prospectively included between July 2012 and July 2014. Transthoracic echocardiography was performed preoperatively and at 1-month follow-up. RESULTS: Sixty-six consecutive patients (mean age, 78 ± 6.4 years; 54.5% women) were included. The Intuity 19 mm was inserted in 29 patients, and the Intuity 21 mm was inserted in 37 patients. No deaths or aortic annulus ruptures occurred. Mean aortic cross-clamp time was 42.7 ± 18.2 minutes. At the 1-month follow-up, mean New York Heart Association classification was 1.6 ± 0.5 versus 2.2 ± 0.8 (p < 0.001). The mean gradient decreased from 59 ± 17.6 mm Hg to 13.7 ± 4.4 mm Hg (p < 0.001). Mean indexed effective orifice area was 0.77 ± 0.17 cm(2)/m(2) for the Intuity 19 mm and 1.01 ± 0.32 cm(2)/m(2) for the Intuity 21 mm. Twenty-one patients (32%) had a moderate PPM (indexed effective orifice area < 0.85 cm(2)/m(2)), and 10 patients (15%) had a severe PPM (indexed effective orifice area < 0.65 cm(2)/m(2)). The mean gradient was 15.1 ± 3.5 mm Hg and 16.9 ± 4.9 mm Hg in the moderate PPM group and severe PPM group, respectively (p = 0.3). The left ventricular mass index dramatically decreased from 153.2 ± 32.7 g/m(2) to 118.4 ± 20.2 g/m(2) (p < 0.001), and only 1 patient (1.5%) had a periprosthetic regurgitation greater than 1. CONCLUSIONS: Regarding the low rate of severe PPM and the early regression of left ventricular mass, these preliminary studies indicate the potential benefit of the Intuity bioprosthesis in patients with a small aortic annulus. Midterm results should be evaluated.

Infective endocarditis: prevention, diagnosis, and management.

Infective endocarditis (IE) is among the most severe infectious disease, the prevention of which has not decreased its incidence. The age of patients and the rate of health care-associated IE have increased as a consequence of medical progress. The prevention strategies have been subjected to an important debate and nonspecific hygiene measures are now placed above the use of antibiotic prophylaxis. Indeed, the level of evidence of antibiotic prophylaxis efficiency is low and the indications of its prescription have been restricted in the recent international guidelines. In cases carrying a high suspicion of IE, efforts should be made to rapidly identify patients with a definite or highly probable diagnosis of IE and to find the causative pathogen to ensure that appropriate treatment, including urgent valvular surgery, begins promptly. Although echocardiography remains the main accurate imaging modality to identify endocardial lesions associated with IE, it can be negative or inconclusive especially in cases of prosthetic valve or other intracardiac devices. Recent studies demonstrated the diagnostic value of other imaging strategies including cardiac computed tomography (CT), positron emission tomography/CT, radiolabelled leukocyte single-photon emission CT/CT, and cerebral magnetic resonance imaging. Novel perspectives on the management of endocarditis are emerging and offer a hope for decreasing the rate of residual deaths by accelerating the processes of diagnosis, risk stratification, and instauration of antimicrobial therapy. Moreover, the rapid transfer of high-risk patients to specialized mediosurgical centres (IE team), the development of new surgical modalities, and close long-term follow-up are of crucial importance.

Latent Q fever endocarditis in patients undergoing routine valve surgery.

BACKGROUND AND AIM OF THE STUDY: Q fever is a worldwide zoonosis caused by a fastidious bacterium, Coxiella burnetii. A recent major outbreak of which in the Netherlands will most likely lead to the emergence of hundreds of cases of C. burnetii endocarditis during the next decade. Patients undergoing cardiac valve surgery may carry undiagnosed Q fever endocarditis with possible disastrous outcomes, and hence may benefit from a screening strategy. The study aim was to evaluate the frequency of unsuspected latent Q fever endocarditis in patients undergoing routine valve surgery. METHODS: At the present authors' institution, all resected cardiac valves/prostheses are examined routinely histologically, microbiologically and on a molecular biological basis, in addition to serological testing for fastidious microorganisms. A retrospective review was conducted of data relating to all patients who had unsuspected Q fever endocarditis that had been diagnosed after routine valve/prosthesis replacement/repair between 2000 and 2013 at the authors' institution. RESULTS: Among 6,401 patients undergoing valve surgery, postoperative examinations of the explanted valves/prostheses led to an unexpected diagnosis of Q fever endocarditis in 14 cases (0.2%), who subsequently underwent appropriate medical treatments. Only two of the patients (14%) had intraoperative findings suggestive of endocarditis. On serological analysis of the blood samples, 11 patients (79%) presented an evocative Phase I IgG antibody titer > or =800. Valvular tissue-sample analyses yielded positive cultures and PCR in the same 13 patients (93%), whereas pathological and immunohistochemical examinations alone were suggestive of endocarditis in only seven Cases (50%). CONCLUSION: This screening strategy led to an unexpected diagnosis of Q fever endocarditis in 0.2% of patients undergoing routine valve surgery, who received subsequent appropriate antibiotic therapy. Systematic serological analysis should be mandatory before performing heart valve surgery in countries where C. burnetii is endemic. A positive serology should lead to appropriate valve-specimen analyses, including microbiological, molecular biological and histological evaluations.

Reoperation for failure of freestyle bioprosthesis using an Edwards intuity valve.

We report the first case of a successful implantation of the new Edwards Intuity rapid-deployment bioprosthesis in a 50-year-old man with acute failure of a Freestyle Medtronic root with severe aortic regurgitation and massive calcification of the root and both coronary buttons.

Persistence of DNA in a cured patient and positive culture in cases with low antibody levels bring into question diagnosis of Q fever endocarditis.

We evaluated the performance of tools for diagnosing Q fever cardiovascular infection. We retrospectively analyzed 162 cardiovascular samples from 125 patients who were tested serologically by immunofluorescence, quantitative PCR (qPCR), 16S rRNA gene amplification, culture, and immunohistochemistry, and we assessed the viability of Coxiella burnetii by measuring the transcription of the 16S rRNA gene. The qPCR technique was significantly more sensitive than 16S rRNA gene amplification (P < 0.0001), cell culture (P = 0.0002), and immunohistochemistry (P < 0.0001). The sensitivity of these techniques was reduced when applied to patients who had been previously treated. The severity of infection appears to be correlated with phase I IgG levels. We report for the first time 4 cases of endocarditis with positive qPCR and/or culture assay result from patients with a low phase I IgG (IgG I) titer (<800), and we have identified the longest (16 years) persistence of DNA described in a heart valve from a patient cured after being previously treated for endocarditis. The active transcription of the 16S rRNA gene was found in 19/59 tested samples, with a positive predictive value of 100% for a positive culture. In conclusion, the diagnosis of Q fever cardiovascular infection should not be excluded in patients with low titers of phase I IgG when they present with valvulopathy. We recommend testing cardiovascular samples using 3 or 4 different biopsy sections by qPCR evaluation for patients with IgG I titers of ≥200.

Three-dimensional transesophageal echocardiography assessment of a successful transcatheter mitral valve in valve implantation for degenerated bioprosthesis.

Reoperation for degenerated mitral bioprosthesis is considered a high risk procedure. Transcatheter mitral valve in valve implantation has emerged as an off-label alternative for patients contra-indicated to surgery. We report a 46-year-old man, with a 29 mm mitral bioprosthesis since 2002, who was admitted for acute heart failure because of a severe intra-prosthetic regurgitation. His recent medical history revealed a fast growing cavum carcinoma. In view of generally poor prognosis, the heart team decided to perform a transcatheter mitral valve in valve implantation by transapical approach. Live three-dimensional TEE was used during the implantation for sizing, device positioning, and hemodynamic assessment.

Risk of reoperation for mitral bioprosthesis dysfunction.

BACKGROUND AND AIM OF THE STUDY: Today, when a mitral valve replacement is required, more patients and surgeons choose a bioprosthesis. Yet, the rationale of this choice is unclear in patients in whom age represents a predicting factor for reoperation. The study aim was to define the risk factors for reoperation after mitral bioprosthesis failure. METHODS: A total of 282 consecutive patients (202 women, 80 men; mean age at surgery 61 years; range: 28-88 years) who underwent reoperation for mitral bioprosthesis failure between 1990 and 2006 was reviewed. Surgery was undertaken because of bioprosthesis degeneration (91%), prosthetic valve infective endocarditis (6%), paravalvular leak (2%), or other causes (1%). Emergency procedures were performed in 7% of cases. Associated procedures included tricuspid valve surgery in 16% of patients (tricuspid valve repair in 11%, tricuspid valve replacement in 5%) and coronary artery bypass graft in 5%. Almost one-fifth of patients (18%) had undergone more than one previous mitral valve replacement. RESULTS: The overall operative mortality was 7.4% (n = 21). Factors identified (by multivariate analysis) as predictors of operative death included: presence of diabetes mellitus (odds ratio (OR) = 8.69, 95% CI 2.55-29.61; p = 0.001), chronic obstructive pulmonary disease (OR = 9.01, 95% CI 1.72-47.18; p = 0.009), NYHA class III/IV (OR 5.46, 95% CI 1.41-21.16; p = 0.01), and pulmonary artery pressure > 60 mmHg (OR = 3.13, 95% CI 1.10-8.94; p = 0.03). Associated procedures were not significant risk factors for mortality. New prostheses were mechanical in 68% of cases, and bioprostheses in 32%. CONCLUSION: One reoperation for mitral bioprosthesis dysfunction is acceptable if the patient can be expected to survive to reoperation while free from comorbidities and the severe effects of mitral disease. The application of strict selective criteria to recipients at the first valve replacement, combined with a close follow up, may allow this goal to be achieved.

Management of infective endocarditis: challenges and perspectives.

Despite improvements in medical and surgical therapies, infective endocarditis is associated with poor prognosis and remains a therapeutic challenge. Many factors affect the outcome of this serious disease, including virulence of the microorganism, characteristics of the patients, presence of underlying disease, delays in diagnosis and treatment, surgical indications, and timing of surgery. We review the strengths and limitations of present therapeutic strategies and propose future directions for better management of endocarditis according to the most recent research. Novel perspectives on the management of endocarditis are emerging and offer hope for decreasing the rate of residual deaths by accelerating the process of diagnosis and risk stratification, reducing delays in starting antimicrobial therapy, rapid transfer of high-risk patients to specialised medico-surgical centres, development of new surgical methods, and close long-term follow-up.

DNA persistence and relapses questions on the treatment strategies of Enterococcus infections of prosthetic valves.

We used amplification of the 16S rRNA gene followed by sequencing to evaluate the persistence of bacterial DNA in explanted heart valve tissue as part of the routine work of a clinical microbiology laboratory, and we analyzed the role of this persistence in the relapses observed in our center. We enrolled 286 patients treated for infective endocarditis (IE) who had valve replacement surgery and were diagnosed according to the modified Duke's criteria described by Li et al. from a total of 579 IE cases treated in our center. The patients were grouped based on the infecting bacteria, and we considered the 4 most common bacterial genus associated with IE separately (144 were caused by Streptococcus spp., 52 by Enterococcus spp., 58 by Staphylococcus aureus and 32 by coagulase-negative Staphylococcus). Based on our cohort, the risk of relapse in patients with enterococcal prosthetic valve infections treated with antibiotics alone was 11%. Bacterial DNA is cleared over time, but this might be a very slow process, especially with Enterococcus spp. Based on a comprehensive review of the literature performed on Medline, most reports still advise combined treatment with penicillin and an aminoglycoside for as long as 4-6 weeks, but there has been no consensus for the treatment of enterococcal infection of prostheses in IE patients.

An atypical case of acute myocardial infarction.

Most ST-elevation myocardial infarctions are related to atherothrombosis and benefit from emergent percutaneous coronary intervention. On the other hand, type-A aortic dissection is a less frequent but deadly disease requiring emergent surgery. In the present case, we aimed to report the case of a patient who presented with aortic dissection responsible for STEMI and cardiogenic shock related to a compressive hematoma of the left main trunk. This atypical case underlines the need for careful assessment of the aorta in case of left main trunk occlusion in patients without evidence of atheroma in the other coronary segment. Unfortunately, in this case, refractory cardiogenic shock postponed surgical repair and led to the patient's death.

Graft-to-endograft anastomosis for emergency treatment of distal aortic arch aneurysm after endovascular stenting of thoracoabdominal type B dissection.

Emergency aortic arch surgery still remains a challenge, especially in elderly patients. We report a case about the open surgical management by graft-to-endograft anastomosis of a complicated aortic arch aneurysm because of a type I endoleak after thoracic endovascular aortic repair of a chronic type B aortic dissection.