Hélène Petit

Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection.

Objective:We sought to determine whether assessing D-Dimer might be helpful for the management of acute aortic dissection (AAD). Design:Single-center retrospective case-control study. Setting:University Hospital of Strasbourg France. Patients:Patients were 94 consecutive patients admitted to our institution with confirmed AAD and in whom D-Dimer test had been performed at presentation. These patients were matched with 94 controls presenting with clinical suspicion of dissection, which was later ruled out. Interventions:Patient characteristics and clinical course were analyzed. Measurements and Main Results:Ninety-three (99%) patients with AAD had elevated D-Dimer (>400 ng/mL) with a median D-Dimer value of 8610 ng/mL (interquartile range, 2982–20,000 ng/mL). Receiver operating characteristic curves analysis showed that D-Dimer, but not C-reactive protein, troponin, lactate dehydrogenase, or leukocyte count, was predictive of a diagnosis of AAD, with a sensitivity and specificity of 99% and 34%, respectively. D-Dimer concentration positively correlated with the anatomical extension of the dissection to the different segments of the aorta (R = .47, p < .0001). A positive relationship was observed between D-Dimer and in-hospital mortality rate among patients with AAD (p = .037). On multivariate analysis, the independent predictors of in-hospital mortality were the presence of pericardial effusion (odds ratio, 6.80; confidence interval, 1.87–27.60), D-Dimer >5200 ng/mL (odds ratio, 5.38; confidence interval, 1.27–30.87), and female gender (odds ratio, 4.96; confidence interval, 1.39–19.95). Conclusions:D-Dimers are elevated in patients with AAD and provide valuable diagnostic and prognostic information. In patients with acute chest pain and elevated D-Dimer, a diagnosis of AAD should also be considered. D-Dimer might be a useful complementary tool to the current diagnostic work-up of patients with suspected AAD.

Does carotid eversion endarterectomy and reimplantation reduce the risk of restenosis

Two hundred twelve eversion endarterectomies of the internal carotid artery and reimplantation in the common carotid artery were performed between January 1985 and July 1990. A total of 206 patients with stenosis of 75% or more and with redundancy and tortuosity of the internal carotid artery underwent this procedure. Cumulative mortality and neurologic morbidity were 2.4%. Forty patients died during the course of follow-up, seven of neurologic causes (17.1%). Duplex scans of 107 operated carotid arteries were obtained an average of 27.1 months after surgery. Restenosis of >50% was encountered in three patients (1.9%), two asymptomatic patients (1.3%) with >75% restenosis and one symptomatic patient with occlusion (0.6%). These results contrast with a 13.5% rate of restenosis >50% (including 5.9% of restenoses >75% and 1.7% occlusions) observed after 156 consecutive endarterectomies performed and closed by direct suture by the same surgical team in 1987 at a mean follow-up of 44 months. We believe that this technique can be used more often because the operative and long-term risks are not any greater than those of the other methods of carotid revascularization. Eversion endarterectomy associated with reimplantation is especially indicated when the internal carotid artery is elongated, is <4 mm wide, and occurs in women.

Clinical Presentation and Treatment Options for Mitral Valve Myxoma

Myxomas rarely are located on the mitral valve. We report the case of a 44-year-old man operated on successfully with mitral valve conservation, which is the 21st case of mitral valve myxoma reported in the western literature. Among the cases reported in the literature, the diagnosis was made at the time of autopsy in 6 cases, with premortem heart failure in 1 case. A clinical diagnosis was made in 15 cases on the basis of the following symptoms: peripheral embolism in 9 cases, cardiac signs in 4 cases, and constitutional manifestations in 2 cases. The clinical presentation of mitral valve myxoma differs slightly from that of other cardiac myxomas in that it has a lower incidence of constitutional manifestations. The gold standard for noninvasive diagnosis and localization of cardiac myxomas is transesophageal echocardiography. It allows for the detection of early, small valvular tumors and may help to characterize better their location and echostructure, facilitating the choice of an optimal surgical approach through preoperative study of the integrity and mobility of the valve. Conservative operative treatment by resection of the area of implantation of the myxoma followed by suture repair of the valve and annuloplasty may be recommended as the most appropriate treatment option for this rare condition.

Lower circulating Sta-Liatest D-Di levels in patients with aortic intramural hematoma compared with classical aortic dissection

Objective:To compare the diagnostic value of circulating Sta-Liatest D-Di levels in classic acute aortic dissection (AAD) and in aortic intramural hematoma (AIH), a variant of AAD without a patent false lumen. Design:Single-center retrospective case-control study. Setting:University Hospital of Strasbourg, France. Patients:Ninety-four consecutive patients with both confirmed AAD and d-dimer measurements at entry were included. d-dimer levels were assayed by the immunoturbidimetric method Sta-Liatest D-Di (Diagnostica Stago, Asnieres sur Seine, France). Intervention:Patient characteristics and clinical evolution were analyzed. Measurements and Main Results:Eighty-four patients (89%) presented a classic AAD with patent false lumen and ten (11%) presented an AIH. Clinical presentation did not differ between the two groups. The mortality rate was 0% in AIH and 26% in classic AAD. d-dimer levels were significantly lower in patients with AIH (median, 1230 ng/mL; interquartile range, 685–2645 ng/mL) than in patients with AAD with patent false lumen (median value, 9290 ng/mL; interquartile range, 3890–20,000 ng/mL; p = 0.008). All patients with AAD and patent false lumen had d-dimer levels above the threshold of 400 ng/mL (sensitivity 100%). However, one patient with AIH presented d-dimer levels below the threshold. Therefore, the sensitivity of the d-dimer test in detecting AIH was 90%. Conclusions:Sta-Liatest D-Di levels are lower in AIH than in AAD with patent false lumen. This test can quite possibly be negative in the case of intramural hematoma. This feature must be considered when interpreting d-dimer levels in patients with acute aortic syndrome.

D-Dimer in ruling out acute aortic dissection: sensitivity is not 100%

We read with great interest the article by Sodeck et al. 1 reporting the negative predictive value of D-Dimer in acute aortic dissection (AAD). Based on a meta-analysis and on a personal series of 65 patients, the authors conclude that current evidence supports a routine measurement of D-Dimer for excluding AAD. Furthermore, a D-Dimer threshold <0.1 µg/mL would exclude AAD in all cases. We previously reported on a 94-case series of patients2 and believe for several reasons that Sodecks conclusion could …

0258: Comparison of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement in very high risk patients, monocentric registry of an early experience

Introduction The PARTNER trial has shown that TAVI is not inferior to surgical aortic valve replacement (AVR) in high-risk aortic stenosis. However, real life registry comparing TAVI and surgery are lacking. Methods monocentric registry of high-risk patients (lEUROSCORE1 ≥15%) undergoing TAVI (114 patients) or AVR (81 patients) between 2009 and 2013 in our institution. Results Mean age was 84,4 and 83,6 yo (p=NS). TAVI patients had higher EUROSCORE1 (31 vs 24.5%, p Conclusion The present registry results confirm that TAVI is a real alternative to surgery in patients with at high surgical risk. Longer follow up is required to confirm these results. Abstract 0258 – Table. AVR TAVI p n 81 114 Age 83.6 84.4 0.21 Euroscore1 (%) 24.5 31 FEV (%) 57.1 48.5 DTVG (mm) 51 54 0.086 Mean Gradient (mmHg) 53 46 0.008 Creatinin pre (microM/L) 111 138 0.003 Hemoglobin pre (g/100) 12.6 11.6 Death (%) 17.3 9.6 0.12 Vascular complication (%) 0 11.4 0.001 Infection (%) 19 11 0.008 Dialysis (%) 13.6 11.4 0.65 AFIB post (%) 41 20 0.002 Pericardial effusion (% ) 2.5 8.8 0.13 Stroke (%) 4.9 1.8 0.23 Pace Maker (%) 4.9 24.6 Transfusions (%) 80 25

0228: Aortic annulus sizing strategy in TAVI, comparison of echocardiography and CT, impact on aortic regurgitation incidence and patients prognosis

Background Aortic regurgitation (AR) after TAVI is the main limitation of this procedure. The aim of this study was to evaluate i) aortic annulus sizing by CT and/or echocardiography (TTE or TEE) ii) the incidence of AR and its determinism iii) the prognostic impact of AR and other survival predictors. Methods 136 consecutive patients undergoing TAVI were included between 2010 and 2013. The aortic annulus sizing for prosthesis choice was done by TEE in 29 patients and by CT in 107 patients. Aortic valve calcium volume was measured by the volume technique in 67% of patients who have got CT. Follow-up was performed at 1, 6, 12 and 24 months. Results Aortic annulus sizing by TTE and TEE echocardiography (TEE) were well correlated (r=0,73, p=0,0001, n=51) but were significantly lower than CT sizing (p 25%, aortic regurgitation ≥ 2/4, renal failure with creatinin> 130μmol/l, anemia after TAVI Conclusion This study showed that aortic annulus sizing by echocardiography is significantly lower than sizing by CT. AR have an independent prognostic on survival. Prevention of aortic regurgitation is an important issue for the future of this technique.