Calcification of surgical aortic bioprostheses and its impact on clinical outcome

AIMS

Aortic valve calcification (AVC) of surgical valve bioprostheses (BP) has been poorly explored. We aimed to evaluate in-vivo and ex-vivo BP AVC and its prognosis value.

METHODS AND RESULTS

Between 2011 and 2019, AVC was assessed using in-vivo computed tomography (CT) in 361 patients who had undergone surgical valve replacement 6.4±4.3 years earlier. Ex-vivo CT scans were performed for 37 explanted BP. The in-vivo CT scans were interpretable for 342 patients (19 patients [5.2%], were excluded). These patients were 77.2±9.1 years old and 64.3% were male. Mean in-vivo AVC was 307±500 Agatston unit (AU). The AVC was 562±570 AU for the 183 (53.5%) patients with structural valve degeneration (SVD) and 13±43 AU for those without SVD (p<0.0001). In-vivo and ex-vivo AVC were strongly correlated (r=0.88, p<0.0001). An in-vivo AVC>100 AU (n=147, 43%) had a specificity of 96% for diagnosing Stage 2-3 SVD (area under the curve=0.92). Patients with AVC>100 AU had a worse outcome compared with those with AVC≤100 AU (n=195). In multivariable analysis, AVC was a predictor of overall mortality (hazard ratio [HR] and 95% confidence interval=1.16[1.04-1.29]; p=0.006), cardiovascular mortality (HR=1.22[1.04-1.43]; p=0.013), cardiovascular events (HR=1.28 [1.16-1.41]; p<0.0001), and re-intervention (HR=1.15 [1.06-1.25]; p<0.0001). After adjustment for Stage 2-3 SVD diagnosis, AVC remained a predictor of overall mortality (HR=1.20 [1.04-1.39]; p=0.015) and cardiovascular events (HR=1.25 [1.09-1.43]; p=0.001).

CONCLUSION

CT scan is a reliable tool to assess BP leaflet calcification. An AVC>100 AU is tightly associated with SVD and it is a strong predictor of overall mortality and cardiovascular events.

Replacement Myocardial Fibrosis in Patients With Mitral Valve Prolapse: Relation to Mitral Regurgitation, Ventricular Remodeling, and Arrhythmia

BACKGROUND

Mitral valve prolapse (MVP) is a frequent disease that can be complicated by mitral regurgitation (MR), heart failure, arterial embolism, rhythm disorders, and death. Left ventricular (LV) replacement myocardial fibrosis, a marker of maladaptive remodeling, has been described in patients with MVP, but the implications of this finding remain scarcely explored. We aimed at assessing the prevalence, pathophysiological and prognostic significance of LV replacement myocardial fibrosis through late gadolinium enhancement (LGE) by cardiac magnetic resonance in patients with MVP.

METHODS

Four hundred patients (53±15 years of age, 55% male) with MVP (trace to severe MR by echocardiography) from 2 centers, who underwent a comprehensive echocardiography and LGE cardiac magnetic resonance, were included. Correlates of replacement myocardial fibrosis (LGE+), influence of MR degree, and ventricular arrhythmia were assessed. The primary outcome was a composite of cardiovascular events (cardiac death, heart failure, new-onset atrial fibrillation, arterial embolism, and life-threatening ventricular arrhythmia).

RESULTS

Replacement myocardial fibrosis (LGE+) was observed in 110 patients (28%; 91 with myocardial wall including 71 with basal inferolateral wall, 29 with papillary muscle). LGE+ prevalence was 13% in trace-mild MR, 28% in moderate MR, and 37% in severe MR, and was associated with specific features of mitral valve apparatus, more dilated LV and more frequent ventricular arrhythmias (45% versus 26%, P<0.0001). In trace-mild MR, despite the absence of significant volume overload, abnormal LV dilatation was observed in 16% of patients and ventricular arrhythmia in 25%. Correlates of LGE+ in multivariable analysis were LV mass (odds ratio, 1.01 [95% CI, 1.002-1.017], P=0.009) and moderate-severe MR (odds ratio, 2.28 [95% CI, 1.21-4.31], P=0.011). LGE+ was associated with worse 4-year cardiovascular event-free survival (49.6±11.7 in LGE+ versus 73.3±6.5% in LGE-, P<0.0001). In a stepwise multivariable Cox model, MR volume and LGE+ (hazard ratio, 2.6 [1.4-4.9], P=0.002) were associated with poor outcome.

CONCLUSIONS

LV replacement myocardial fibrosis is frequent in patients with MVP; is associated with mitral valve apparatus alteration, more dilated LV, MR grade, and ventricular arrhythmia; and is independently associated with cardiovascular events. These findings suggest an MVP-related myocardial disease. Last, cardiac magnetic resonance provides additional information to echocardiography in MVP.

The added value of contrast-enhanced cardiac magnetic resonance to predict positive genetic testing in clinically suspected Lamin A/C cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Background

Lamin A/C cardiomyopathy (CM) is an inherited disease due to LMNA gene mutation with particular phenotype that associates conduction disorders, frequent atrial fibrillation and life-threatening ventricular arrhythmias, with normal or altered ventricular systolic function. Cardiac magnetic resonance (CMR) studies suggest frequent late gadolinium enhancement (LGE) involving septal mid-myocardium. 

Aims

To assess the added value of CMR to conventional clinical features of Lamin A/C CM for the prediction of a positive LMNA gene testing. 

Methods

We performed a retrospective monocentric study in all index patients referred for genetic testing for a clinical suspicion of Lamin A/C CM. Clinical, ECG and imaging data including CMR at time of genetic testing in patients with a positive test (LMNA+) and patients without (LMNA-) were compared. The diagnostic performances of relevant parameters for the prediction of a positive LMNA gene testing were analyzed in several logistic regression models. 

Results

90 patients were included (55 LMNA+, 35 LMNA-).49% had significant left ventricular (LV) dilatation on echocardiography,57% had a LV ejection fraction (LVEF)&lt;50%, 46% had a significant left atrial dilatation, and 17% had right ventricular dysfunction. None of these parameters were different comparing LMNA+ and LMNA- patients. LMNA+ patients had significantly more frequent familial history of sudden cardiac death (SCD) or CM. There were no significant differences between LMNA+ and LMNA- patients in terms of conduction disorders, ventricular and supra-ventricular arrhythmias. The only significant difference on ECG was a more frequent abnormal R-wave progression in V1-V3 in LMNA+ patients (87.8% vs 39.4%, p &lt; 0.001). 55 patients had a CMR (28/55 LMNA+, 27/35 LMNA-). The main reason for not performing CMR was the presence of cardiac implantable electronic device. LMNA+ patients had significantly more LGE than LMNA- (20/28 (71%) vs 9/27 (33%), p = 0.011). The main differences in LGE features between the 2 groups were septal involvement (70% in LMNA+ vs 11% in LMNA-, p = 0.005) and mid-myocardium localization (95% vs 44%, p = 0.005). In a first logistic regression model without CMR data in all 90 patients, V1-V3 R-wave abnormalities, familial history of SCD and sinus node dysfunction were independent predictors of a positive LMNA gene testing (Sensitivity 89%, specificity 46%, accuracy 72%). A second model in the 55 patients who had a CMR showed better accuracy (85%), mainly driven by increased specificity (81%) with preserved sensitivity (89%). V1-V3 R-wave abnormalities, premature ventricular contractions, non-depressed LVEF and septal LGE predicted positive LMNA gene testing in this model (Septal LGE OR = 31, 95%CI 4-715; p = 0.005). 

Conclusion

CMR, particularly septal mid-myocardium LGE, carries good diagnostic accuracy to predict a positive LMNA gene testing in clinically suspected Lamin A/C CM with increased specificity when added to conventional red flags.

Abstract Figure. Logistic regression models performances

Determinants and prognostic significance of focal myocardial fibrosis by cardiac magnetic resonance imaging in patients with mitral valve prolapse

Background

Mitral valve prolapse (MVP) is a frequent disease that can be complicated by mitral regurgitation (MR), heart failure, arterial embolism, rhythm disorders and death.

Purpose

We sought to evaluate the correlates of late gadolinium enhancement (LGE), and the prognostic significance of ventricular size, function, and LGE by cardiac magnetic resonance (CMR) imaging on cardiovascular morbi-mortality in patients with MVP

Methods

We included 426 patients (54±15 years, 57% male) with MVP (trace to severe MR) between 2010 and 2019 who underwent a comprehensive echocardiography and CMR imaging. Gadolinium was injected in 411 (96%) patients. The main outcome endpoint was a composite endpoint of cardiovascular death, heart failure, new onset atrial fibrillation or arterial embolism, censored at the time of mitral valve intervention.

Results

Among the 411 patients, LGE+ was found in 118 (29%; 100 myocardial wall including 78 basal inferolateral midwall, 30 papillary muscles) and was more frequent with worse MR volume and LV remodeling. Correlates of LGE in multivariable analysis were LV mass index (OR 1.02, P=0.008), moderate-severe MR (OR 2.15, P=0.017) and coronary artery disease (OR 5.8, P=0.013). At 4 years, survival without cardiovascular events was decreased in patients with LGE+ (50.0±11.9 vs 73.5±6.3%, p&lt;0.0001). In a stepwise multivariable analysis including classical predictors of outcome, grade of MR, LA volume index and the presence of LGE on CMR imaging (HR: 2.15 [1.15–4.02], P=0.017) were associated with impaired event-free survival.

Conclusion

CMR imaging provides additional information to echocardiography in the clinical work-up of MVP. Localized LV myocardial fibrosis is a predictor of cardiovascular event in MVP patients.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): DGOS (PHRCI), Fondation Cœur et Recherche

Pediatric cardiac computed tomography angiography: Expert consensus from the Filiale de Cardiologie Pédiatrique et Congénitale (FCPC) and the Société Française d'Imagerie Cardiaque et Vasculaire diagnostique et interventionnelle (SFICV)

This article was designed to provide a pediatric cardiac computed tomography angiography (CCTA) expert panel consensus based on opinions of experts of the Société Française d'Imagerie Cardiaque et Vasculaire diagnostique et interventionnelle (SFICV) and of the Filiale de Cardiologie Pédiatrique Congénitale (FCPC). This expert panel consensus includes recommendations for indications, patient preparation, CTA radiation dose reduction techniques, and post-processing techniques. The consensus was based on data from available literature (original papers, reviews and guidelines) and on opinions of a group of specialists with extensive experience in the use of CT imaging in congenital heart disease. In order to reach high potential and avoid pitfalls, CCTA in children with congenital heart disease requires training and experience. Moreover, pediatric cardiac CCTA protocols should be standardized to acquire optimal images in this population with the lowest radiation dose possible to prevent unnecessary radiation exposure. We also provided a suggested structured report and a list of acquisition protocols and technical parameters in relation to specific vendors.

Familial screening in case of acute myocarditis reveals inherited arrhythmogenic left ventricular cardiomyopathies

Aims

Several data suggest that acute myocarditis could be related to genetic variants involved in familial cardiomyopathies, particularly arrhythmogenic cardiomyopathy, but the management of patients with acute myocarditis and their families regarding their risk for having an associated inherited cardiomyopathy is unclear.

Methods and results

Families with at least one individual with a documented episode of acute myocarditis and at least one individual with a cardiomyopathy or a history of sudden death were included in the study. Comprehensive pedigree, including genetic testing, and history of these families were analysed. Six families were included. Genetic analysis revealed a variant in desmosomal proteins genes in all the probands [five in desmoplakin (DSP) gene and one in desmoglein 2 gene]. In the five families identified with a DSP variant, genetic testing was triggered by the association of an acute myocarditis with a single case of apparently isolated dilated cardiomyopathy or sudden death. Familial screening identified 28 DSP variant carriers; 39% had an arrhythmogenic left ventricular (LV) cardiomyopathy phenotype. Familial histories of sudden death were frequent, and a remarkable phenotype of isolated LV late gadolinium enhancement on contrast‐enhanced cardiac magnetic resonance without any other structural abnormality was found in 38% of asymptomatic mutation carriers. None of the DSP variant carriers had imaging characteristics of right ventricle involvement meeting current Task Force criteria for arrhythmogenic right ventricular cardiomyopathy.

Conclusions

Comprehensive familial screening including genetic testing in case of acute myocarditis associated with a family history of cardiomyopathy or sudden death revealed unknown or misdiagnosed arrhythmogenic variant carriers with left‐dominant phenotypes that frequently evade arrhythmogenic right ventricular cardiomyopathy Task Force criteria. In view of our results, acute myocarditis should be considered as an additional criterion for arrhythmogenic cardiomyopathy, and genetic testing should be advised in patients who experience acute myocarditis and have a family history of cardiomyopathy or sudden death.

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 &lt; 60% and RV EF &lt; 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 &lt; 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.

P3697A reappraisal of bioprosthetic aortic valve failure related to structural valve degeneration

Background

Structural valve degeneration (SVD) remains a major complication of aortic bioprostheses.

Purpose

We aimed to assess the mode of SVD leading to bioprosthetic aortic valve failure (BVF) in a large series of patients.

Methods

Between 2010 and 2017, we prospectively enrolled 261 consecutive patients with BVF related to SVD. All patients underwent a clinical work-up. Explanted bioprostheses were analysed for assessing the mechanism of SVD.

Results

The delay from surgery to SVD diagnosis was 8.5±3.3 (1.7 to 21.4) years, 10 years after exclusion of a specific type of bioprosthesis. Of the 261 SVD patients, 150 (57%) had mainly a stenotic type, and 111 (43%) a regurgitant type. In regurgitant SVD bioprosthesis was more frequently porcine (19 vs 7%, P=0.002), prosthesis diameter was larger (23.2±2.5 vs 21.6±1.9 mm; P<0.0001), severe mismatch was less frequent (6 vs 17%, P=0.005), cardiovascular risk factors and especially diabetes, obesity and hypertension were less frequent, patients were more often in NYHA class 3–4 (64 vs 49%; p=0.015), Nt-pro BNP was significantly higher (P<0.0001), and diuretic treatment was more frequent (73 vs 61%, P=0.04). Bioprostheses were explanted during redo surgery in 112 (43%) patients. Of these 112 bioprostheses, moderate to severe calcifications were present in 94 (83.9%) and was the main cause of either stenotic (n=64, 57.1%) or regurgitant SVD. A cusp tear (n=46) accounted for 41.1% of the explanted SVD. A perforation, a recent thrombus or a delamination process were occasionally identified. Structural degeneration developed with minimal calcification in 18 (16.1%) bioprostheses.

Conclusion

Structural valve degeneration remains a matter of concern in current practice with a mean delay of 8 to 10 years after surgery. Beside classical SVD with extensive calcification process other types of SVD can be observed with minimal calcification.

[Multimodality imaging in the cardiac catheterization laboratory]

Cardiac catheterization has greatly contributed to the progress made in the management of congenital heart diseases (CHD). Initially used in diagnosis, it allowed the understanding of heart diseases, their anatomy and hemodynamics. Gradually, the development of interventional cardiology has played a major role in the management of these malformations (Patent ductus arteriosus [PDA] and atrial septal defect [ASD] closure, pulmonary dilatation, percutaneous pulmonary valve implantation…). The development of such technology was made possible through the concomitant development of imaging techniques: fluoroscopy, ultrasound, MRI and CT. Imaging should provide an accurate view of the lesions, the surrounding cardiac structures, as well as medical devices and catheters used. Here we address the field of fusion images. The principle of image fusion is based on the association by superposition of several imaging techniques: real-time fluoroscopy and slice imaging performed offline, or ultrasound imaging performed simultaneously. The goal is to improve the overall view of the organ, its surrounding structures and as the consequence to help the interventional cardiologist.

Computed tomography imaging in children with congenital heart disease: Indications and radiation dose optimization

Computed tomography (CT) technology is acquiring a key role in the diagnostic process of complex cardiac congenital anomalies. Recent advances and improvements in spatial and temporal resolution and radiation dose are encouraging the use of CT scanning in children. Paediatric cardiologists should have a good knowledge of the potential of CT techniques and their limitations to plan and properly perform CT examinations without forgetting radiation concerns. In this paper, we will discuss the principal indications for CT scans in newborns and children in our clinical practice. We will also outline the most-used strategies for dose reduction. Basic knowledge about the various CT techniques is crucial, not only to perform, but also to interpret CT results, thus helping the medical and surgical management of patients.

Diagnostic and medical strategy for renovascular hypertension: report from a monocentric pediatric cohort

Renovascular hypertension accounts for 5-10 % of hypertension cases in children; there is currently no consensus on treatment. Here, we report on our clinical experience with this disease and outline the different pathways in which to investigate it. We report retrospectively on ten children diagnosed with renovascular hypertension at the University Hospital of Nantes from 2001 to 2012. The main findings were obtained by fortuitous screening of children aged 2 months to 14 years old with neurofibromatosis (n = 2) and fibromuscular dysplasia (n = 8). The hypertension was always severe yet asymptomatic. Lesions were complicated in nine out of ten cases and included bilateral, multiple, mid-aortic syndrome and aneurysm. Doppler ultrasound associated with computed tomography allowed for a precise diagnosis in seven out of ten cases. Where ambiguities persisted, they were highlighted by arteriography, the gold standard investigation. Medical treatment was insufficient, leading to invasive procedures in nine out of ten children: 2 nephrectomies, 2 autotransplantations, and 21 repetitive percutaneous transluminal angioplasties. After invasive procedures, blood pressure control improved in four cases and was resolved in three.

CONCLUSION

Arteriography remains to be the gold standard technique for renovascular hypertension in children and can be combined with angioplasty when medical treatment is rendered obsolete. The role of computed tomography is controversial. Despite the heterogeneity of the children studied, we present a general medical and therapeutic management pathway for the treatment of this disease.

Single high-dose erythropoietin administration immediately after reperfusion in patients with ST-segment elevation myocardial infarction: results of the erythropoietin in myocardial infarction trial

BACKGROUND

Preclinical studies and pilot clinical trials have shown that high-dose erythropoietin (EPO) reduces infarct size in acute myocardial infarction. We investigated whether a single high-dose of EPO administered immediately after reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) would limit infarct size.

METHODS

A total of 110 patients undergoing successful primary coronary intervention for a first STEMI was randomized to receive standard care either alone (n = 57) or combined with intravenous administration of 1,000 U/kg of epoetin β immediately after reperfusion (n = 53). The primary end point was infarct size assessed by gadolinium-enhanced cardiac magnetic resonance after 3 months. Secondary end points included left ventricular (LV) volume and function at 5-day and 3-month follow-up, incidence of microvascular obstruction (MVO), and safety.

RESULTS

Erythropoietin significantly decreased the incidence of MVO (43.4% vs 65.3% in the control group, P = .03) and reduced LV volume, mass, and function impairment at 5-day follow-up (all P < .05). After 3 months, median infarct size (interquartile range) was 17.5 g (7.6-26.1 g) in the EPO group and 16.0 g (9.4-28.2 g) in the control group (P = .64); LV mass, volume, and function were not significantly different between the 2 groups. The same number of major adverse cardiac events occurred in both groups.

CONCLUSIONS

Single high-dose EPO administered immediately after successful reperfusion in patients with STEMI did not reduce infarct size at 3-month follow-up. However, this regimen decreased the incidence of MVO and was associated with transient favorable effects on LV volume and function.

Cerebral ischemia complicating intracranial aneurysm: a warning sign of imminent rupture?

BACKGROUND AND PURPOSE

Patients harboring nongiant cerebral aneurysms may rarely present with an ischemic infarct distal to the aneurysm. The aim of this case series was to report clinical and radiologic characteristics of these patients, their management, and outcome.

MATERIALS AND METHODS

We undertook a single-center retrospective analysis of consecutive patients admitted during an 8-year period with an acute ischemic stroke revealing an unruptured nongiant (<25 mm) sacciform intracranial aneurysm. Clinical, radiologic, therapeutic, and follow-up data were analyzed.

RESULTS

Nine patients were included. The mean size of aneurysms was 9.6 ± 6 mm, and 5 were partially or totally thrombosed. Two patients had a fatal SAH within 3 days after stroke-symptom onset, whereas asymptomatic meningeal bleeding was diagnosed or suspected in 2 others. Most of the patients with unthrombosed aneurysms were successfully treated by endovascular coiling in the acute phase. Thrombosed aneurysms were usually treated with antithrombotics, and most recanalized secondarily, requiring endovascular treatment or surgical obliteration. No recurrence of an ischemic event or SAH was observed during the 31 ± 12 months of follow-up (from 4 to 53 months).

CONCLUSIONS

In this single-center series, the frequency of early SAH in patients with ischemic stroke distal to an unruptured intracranial aneurysm was high. Acute management should be undertaken with care regarding antithrombotic use, and early endovascular coiling should be considered.

Imaging and modern assessment of the right ventricle

The right ventricular function is difficult to assess owing to its complex morphology, structure and function. The right ventricle (RV) comprises three compartments, the inlet, the apex, and the outlet contracting with a peristaltic motion from the inflow to the outflow chamber and is tightly linked to left ventricular (LV) function through the pulmonary circulation, the interventricular septum and the myocardium inside the pericardial envelop. The relation of RV function to symptom occurrence, exercise capacity and prognosis in a wide variety of cardiac diseases emphasizes the usefulness of its routine assessment. The evaluation of the RV is largely carried out by echocardiography in daily clinical practice despite important limitations inherent to two-dimensional imaging. Multiple views and numerous parameters allow clinicians to integrate the RV function in the clinical decision-making process. Recent modalities of echocardiography such as myocardial deformation and three-dimensional imaging or exercise echocardiography are promising tools for the assessment of the RV. Cardiac magnetic resonance imaging provides the unique opportunity to image the RV in motion and in three dimensions without the limitation of echogenicity. Therefore, cardiac magnetic resonance imaging is taking a growing place in the assessment of the RV in a wide variety of cardio-pulmonary diseases as pulmonary hypertension, ischemia, arrhythmogenic right ventricular cardiomyopathy, hypertrophic cardiomyopathy, heart failure or congenital heart diseases. Integrating the complex interplay between both ventricles and the pulmonary circulation, this review will discuss the latest results of standard and novel techniques allowing the assessment of RV function by echocardiography and cardiac magnetic resonance imaging, and will provide to the clinicians, facing therapeutic challenges, a comprehensive overview of right heart function.

[Coronary CTA evaluation of the relationship between mitral valve annulus and coronary circulation: implications for percutaneous mitral annuloplasty]

PURPOSE

To evaluate anatomical relationships between mitral annulus (MA), coronary arteries and coronary sinus (CS) in two groups of patients with and without moderate mitral insufficiency on coronary CTA to identify candidates to percutaneous mitral valve annuloplasty via the coronary sinus without risk of coronary artery occlusion. MATERIALS AND METHODS. Fifty-one ECG-gated coronary CTA examinations, obtained during injection of iodinated contrast material on a 16 MDCT were retrospectively reviewed. The mitral valve annulus diameter, anatomical relationships between CS and coronary arteries and MA-CS distance were compared between both patient groups.

RESULTS

The group with mitral insufficiency included 16 patients and the control group included 35 patients. The AP diameter of the MA was 45,7+/-5,2 mm in the group with mitral insufficiency, significantly larger (p=0.0009) compared to the control group (39,3+/-5,9 mm). In 70.4% of cases, the CS was located next to a coronary artery in an overlapping configuration. The unfavorable anatomical configuration with regards to annuloplasty appeared related to mitral insufficiency (p=0.0539). The distance between MA and CS was greatly variable with the CS routinely extending over the left atrial surface: the distance was significantly (p=0.0002) greater for all patients along the posterior surface (8,1+/-3,8 mm) compared to the lateral surface (5,2+/-4,6 mm) with this différence persisting within both groups: p=0.004 for patients with mitral insufficiency and p=0.0001 for control patients.

CONCLUSION

Our results demonstrate the value of coronary CTA in selecting candidates to percutaneous mitral annuloplasty. In 70.4% of cases, the CS overlaps a coronary artery with risk of compression at the time of annuloplasty.

Anévrysmes intracrâniens révélés par une ischémie cérébrale

PURPOSE

To report four cases of patient with an acute ischemic event as a presenting symptom of a berry aneurysm.

PATIENTS AND METHODS

One male and three female (aged range 38 to 65 years) patients were admitted for acute stroke. The neuroradiologic finding disclosed aneurysm thrombosis, inferior to twenty five millimetres in three cases. Lumbar puncture was done in one case and showed subarachnoid haemorrage.

DISCUSSION

We will discuss the hypothesis leading to the mechanism of aneurysm thrombosis. Two theories will be presented: "hemodynamic" and "parietal" modifications. We will propose a management protocol for these patients with atypical presentation of intracranial aneurysms given the potential risk of rupture.

CONCLUSION

The natural history of intracranial aneurysms is still not fully understood. Nevertheless, aneurym thrombosis may occur and lead to ischemic stroke.