[Ruptured sinus of Valsalva aneurysm presenting as an idiopathic pericardial effusion]. / Rupture colmatée d'un anévrisme de valsalva d'évolution favorable après chirurgie.

Aneurysm of the sinus of Valsalva is a rare cardiac condition, which could be either acquired or congenital. The most frequent complication is a rupture into right cavities or more rarely into left cavities or pericardium. Rupture could be either asymptomatic or poorly tolerated with hemodynamic instability, acute heart failure or sudden death. We report the case of a 24-year-old patient with no past medical history presenting with a partially ruptured sinus of Valsalva into the pericardium and in whom the initial diagnosis was idiopathic pericardial effusion; we describe diagnostic modalities and management.

Value of CMR in quantification of paravalvular aortic regurgitation after TAVI.

AIMS: To assess the value of cardiac magnetic resonance (CMR) using phase-contrast velocity mapping for paravalvular aortic regurgitation (PAR) quantification. METHODS AND RESULTS: All patients undergoing transcatheter aortic valve implantation (TAVI) in our centre between November 2012 and August 2013, without CMR-contraindication were included. PAR severity was assessed 5 days after TAVI using: transthoracic echocardiography (TTE) and CMR [regurgitant volume (RV), regurgitant fraction (RF)]. Aortic regurgitation (AR) index was obtained during TAVI. Thirty of 51 patients who underwent TAVI were included (COREVALVE, n = 10; or EDWARDS SAPIEN XT, n = 20). At TTE, PAR was mild in 22, moderate in 3, and severe in 5 patients. Reliable phase-contrast images were acquired at the sino-tubular junction for SAPIEN and at the tubular portion of the ascending aorta for COREVALVE. The reproducibility of CMR was high (coefficient of correlation = 0.99 for intra- and inter-operator variability). At CMR, RV, and RF were significantly (P < 0.0005) correlated with AR severity at TTE, with mean RF values at 9.2 ± 7.6% in mild, 20.3 ± 4.2% in moderate, and 46.8 ± 10.8% in severe PAR. A cut-off value of RF < 14% at CMR accurately discriminated mild from moderate/severe (sensitivity: 100%, specificity: 82%). The mean AR index was 29.4 ± 6 for mild and 13.8 ± 5 for moderate/severe PAR. Three patients had a RF > 14% and a low AR index <25 despite a mild PAR at TTE, suggesting an underestimation at TTE. CONCLUSION: CMR is a reproducible, accurate, and reliable method to assess PAR severity. CMR may allow correcting an underestimation at TTE when AR index is doubtful.

Is intra-aortic balloon pump absolutely contraindicated in type A aortic dissection?

AIM: Circulatory failure following surgery for type A aortic dissection is frequent and associated with a high mortality rate. The intra-aortic balloon pump (IABP) is used to treat postcardiotomy cardiogenic shock but aortic dissection is traditionally a contraindication. In 10 patients we used IABP for severe cardiogenic shock following aortic dissection surgery, here we report on the short and midterm results. METHODS: From January 2000 to April 2008, among 151 patients with type A aortic dissection 10 received a postoperative IABP. False lumen extension was limited to the ascending aorta for 3 patients, reached the arch for 1 and the descending aorta for 6. RESULTS: The device was placed in the operative room (7 patients), intensive care unit (2) and preoperatively (1). IABP was introduced percutaneously except for one who required surgical placement. The mean duration of IABP therapy was 3.8 days. Four patients died, but no death was directly related to IABP. Improvement in hemodynamics allowed 8 patients to be weaned off IABP. None suffered extension of the dissection. Two patients developed IABP-related complications. Six required extrarenal purification. Among the survivors, one died of a stroke at 38 months, 2 recovered the same quality of life and 3 had neurological sequelae without loss of autonomy. CONCLUSION: IABP should only be used as a salvage option in cases of severe cardiogenic shock following type A aortic dissection. No patient suffered device-related aortic rupture or extension of the dissection. High mortality and morbidity underline the gravity of cardiogenic shock in this setting.

Acute type A aortic dissection intimal tears by 64-slice computed tomography: a role for endovascular stent-grafting?

AIM: The goal of this study was to identify physical characteristics of primary intimal tears in patients arriving to the hospital alive with acute type A aortic dissection using 64-multislice computerized tomography (MSCT) in order to determine anatomic feasibility of endovascular stent-grafting (ESG) for future treatment. METHODS: Radiology database was screened for acute type A aortic dissection since the time of acquisition of the 64-slice CT scanner and cross-referenced with surgical database. Seventeen patients met inclusion criteria. Images were reviewed for number, location, and size of intimal tears and aortic dimensions. Potential obstacles for ESG were determined. RESULTS: Ascending aorta (29%) and sinotubular junction (29%) were the most frequent regions where intimal tears originated. Location of intimal tears in nearly 75% of patients was inappropriate for ESG, and 94% of patients did not have sufficient proximal or distal landing zone required for secure fixation. Only 71% of patients underwent surgical aortic dissection repair after imaging and 86% of entry tears detected on MSCT were confirmed on intraoperative documentation. Only one patient would have met all technical criteria for ESG using currently available devices. CONCLUSION: Location of intimal tear, aortic valve insufficiency, aortic diameter>38 mm are major factors limiting use of ESG for acute type A dissection. Available stents used to treat type B aortic dissection do not address anatomic constraints present in type A aortic dissection in the majority of cases, such that development of new devices would be required.