OBJECTIVES: Despite growing evidence that aortic valve repair improves long-term patient outcomes and quality of life, aortic valves are mostly replaced. We evaluate the effect of aortic valve repair versus replacement in patients with dystrophic aortic root aneurysm up to 4 years. METHODS: The multicentric CAVIAAR (Conservation Aortique Valvulaire dans les Insuffisances Aortiques et les Anevrismes de la Racine aortique) prospective cohort study enrolled 261 patients: 130 underwent standardized aortic valve repair (REPAIR) consisting of remodelling root repair with expansible aortic ring annuloplasty, and 131 received mechanical composite valve and graft replacement (REPLACE). Primary outcome was a composite criterion of mortality, reoperation, thromboembolic or major bleeding events, endocarditis or operating site infections, pacemaker implantation and heart failure, analysed with propensity score-weighted Cox model analysis. Secondary outcomes included major adverse valve-related events and components of primary outcome. RESULTS: The mean age was 56.1 years, and valve was bicuspid in 115 patients (44.7%). Up to 4years, REPAIR did not significantly differ from REPLACE in terms of primary outcome [Hazard Ratio (HR) 0.66 (0.39; 1.12)] but showed significantly less valve-related deaths (HR 0.09 [0.02; 0.34]) and major bleeding events (HR 0.37 [0.16; 0.85]) without an increased risk of valve-related reoperation (HR 2.10 [0.64; 6.96]). When accounting for the occurrence of multiple events in a single patient, the REPAIR group had half the occurrence of major adverse valve-related events (HR 0.51 [0.31; 0.86]). CONCLUSIONS: Although the primary outcome did not significantly differ between the REPAIR and REPLACE groups, the trend is in favour of REPAIR by a significant reduction of valve-related deaths and major bleeding events. Long-term follow-up beyond 4 years is needed to confirm these findings.

A septuagenarian patient with history of high blood pressure was referred to the cardiology clinic for right heart failure. The patient complained of progressive increase of dyspnoea for the past 6 months. Physical examination revealed a 4/6 systolic murmur and signs of right-sided heart failure including important peripheral oedema, jugular venous distension and hepatojugular reflux. The ECG showed normal sinus rhythm (55 beats per minute) with right axis deviation and abnormal repolarisation. The echocardiography (figure 1A) and CT (figure B) are presented (online supplementary video).### Supplementary video [heartjnl-2020-316980supp001.mp4] Figure 1 (A) …

Aortic valve surgery in non-elderly patients represents a very challenging patient population. The younger the patient is at the point of aortic valve intervention, the longer their anticipated life expectancy will be, with longer exposure to valve-related complications and risk for re-operation. Although the latest international guidelines recommend aortic valve repair in patients with aortic valve insufficiency, what we see in the real world is that the vast majority of these aortic valves are replaced. However, current prosthetic valves has now been shown to lead to significant loss of life expectancy for non-elderly patients up to 50% for patients in their 40s undergoing mechanical aortic valve replacement. Bioprostheses carry an even worse long-term survival, with higher rates of re-intervention. The promise of trans-catheter valve-in-valve technology is accentuating the trend of bioprosthetic implantation in younger patients, without yet the appropriate evidence. In contrast, aortic valve repair has shown excellent outcomes in terms of quality of life, freedom from re-operation and freedom from major adverse valve-related events with similar life expectancy to general population as it is also found for the Ross procedure, the only available living valve substitute. We are at a time when the paradigm of aortic valve surgery needs to change for the better. To better serve our patients, we must acquire high quality real-world evidence from multiple centers globally - this is the vision of the AVIATOR registry and our common responsibility.

Objective: Despite growing evidence that aortic valve repair improves long term patient outcomes and quality of life, like mitral valve repair, the aortic valve remained mostly replaced. Main reasons are the lack of multicentric comparative evaluation and the common opinion that replacement reduces the risk of reoperation. Methods: The multicentric CAVIAAR trial enrolled 261 consecutive unselected patients with dystrophic aortic root aneurysm as a prospective cohort comparing 130 patients who underwent a standardized aortic valve repair (REPAIR) associating root remodeling with an expansible aortic ring annuloplasty versus 131 patients with mechanical composite valve and graft replacement (REPLACE). Results: Mean age was 56.1 years, valve was bicuspid in 115 patients (44.7%). Thirty-day mortality was 4.6% (n=6) in both groups (p=1.00). At 4 years, crude and propensity matched analysis confirmed that freedom from valve related death and hemorrhagic events are significantly higher after valve repair than replacement respectively 99.1% vs 94.3% (p < 0.001) and 89.2% vs 78.3% (p=0.02), whereas freedom from valve related reoperation was similar (p=0.223). Furthermore, binomial analysis confirmed that risk of major adverse valve related events is significantly higher after valve replacement (RR=1.94 [1.16-3.24]; p=0.011) with the highest risk of bleeding complications (RR=2.9 (1.37-6.17);p=0.005). Conclusions: A multicentric evaluation of a standardized approach aortic valve repair associating root remodeling with an expansible aortic ring shows a significant reduction of valve related death and complications compared to mechanical valve replacement, without increasing the risk of reoperation.

Objectives: Current national registries are lacking detailed pathology-driven analysis and long-term patients outcomes. The Heart Valve Society (HVS) aortic valve (AV) repair research network started the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) to evaluate long-term patient outcomes of AV repair and replacement. The purpose of the current report is to describe the AVIATOR initiative and report in a descriptive manner the patients included. Methods: The AV repair research network includes surgeons, cardiologists, and scientists and established an online database compliant with the guidelines for reporting valve-related events. Prospective inclusion started from January 2013. Adult patients (18 years or older) who were operated on between 1995 and 2017 with complete procedural specification of the type of repair/replacement were selected for descriptive analysis. Results: Currently 58 centers from 17 countries include 4896 patients with 89% AV repair (n = 4379) versus 11% AV replacement (n = 517). AV repair was either isolated (28%), or associated with tubular/partial root replacement (22%) or valve-sparing root replacement (49%) with an in-hospital mortality of 0.5%, 1.7%, and 1.2%, respectively. AV replacement was either isolated (24%), associated with tubular/partial root replacement (17%) or root replacement (59%) with an in-hospital mortality of 1%, 2.6%, and 2.0%, respectively. Conclusions: The multicenter surgical AVIATOR registry, by applying uniform definitions, should provide a solid evidence base to evaluate the place of repair versus replacement on the basis of long-term patient outcomes. Obtaining data completeness and adequate representation of all surgery types remain challenging. Toward the near future AVIATOR-medical will start to study natural history, as will AVIATOR-kids, with a focus on pediatric disease.

OBJECTIVES:To assess the feasibility and results of 'valve-in-valve' implantation using the 23-mm CoreValve for the treatment of degenerated 19-mm and 21-mm Mitroflow bioprostheses.METHODS:We retrospectively analysed all consecutive patients who underwent transcatheter aortic valve implantation for 19-mm and 21-mm Mitroflow bioprostheses. The height of implantation with respect to the ring of the Mitroflow prosthesis was targeted at -6 mm for the first 3 cases. In the following cases, the target was higher to promote free supra-annular movement of the leaflets.RESULTS:The procedure was successful in 17 of 18 patients (94%). For implantations above the limit of -6 mm, the mean gradient was 10.4 ± 2.6 mmHg compared with 28.1 ± 11.6 mmHg for implantations below the limit of -6 mm (P < 0.01). For patients with severe stenosis as main mechanism of failure of the bioprosthesis, the mean post-procedural gradient was 31.2 ± 11.8 mmHg compared with 12.7 ± 6 mmHg in the absence of severe stenosis (P < 0.01). Patient-prosthesis mismatch (indexed effective orifice area ≤ 0.85 cm2/m2) and severe mismatch (indexed effective orifice area ≤ 0.65 cm2/m2) were present in 83% (15 of 18) and 27% (5 of 18) of patients, respectively. We did not notice any complications following the procedures. Six months after the procedure, functional status was improved in all patients.CONCLUSIONS:Our short series demonstrates the ability to perform transcatheter 'valve-in-valve' implantation in 19-mm and 21-mm Mitroflow prostheses with satisfactory results, but high post-procedural gradients and patient-prosthesis mismatch remain a relatively frequent problem mostly when severe stenosis is the main mechanism of failure. Implantation in a high position is critical to decrease the rate of high postimplantation gradients.

Caseous calcification of the mitral valve usually presents as a circumferential annular density, may spontaneously rupture, and can also involve the aortic valve annulus. We present images of a variant of caseous calcification of the mitral annulus presenting as a discrete, isolated mass. A 71-year-old male underwent aortic valve replacement for severe aortic stenosis. At the time of surgery, transesophageal echocardiography revealed a 1-cm mobile mass originating from the posterior medial aspect of the mitral valve annulus (Figure 1). Following institution of cardiopulmonary bypass and cardioplegic arrest, a left atriotomy revealed that the lesion was a localized area of calcified ulceration involving the posteriormedial commissure (Figure 2). The mass was totally excised without injury to the valvular apparatus. The aortic valve was replaced with a #23 Carpentier-Edwards Perimount Magna bioprosthesis (Edwards Lifesciences, Irvine, CA). The patient tolerated the procedure well. On gross inspection, the lumen of the mass consisted of a creamy fluid which was culture negative. The histology was consistent with caseous calcification with no evidence of any malignancy.

Objectives: To evaluate the role of videothoracoscopic cardiac exploration (VCE) to diagnose and treat stable patients with a chest wound in ‘the cardiac box’.Methods: All hemodynamically stable patients, with a penetrating chest wound close to the heart, were proposed for videothoracoscopy. Pericardoscopy was carried out by introducing the videoendoscope into the pericardium.Results: Eight male patients, average age 25 years (range: 22-42 years), were investigated using VCE. All wound-entry points were in the left hemithorax, and the wounds were inflicted by knives (n=6), a Tahitian arrow (n=1), and an air-compressed nail (n=1). Pericardoscopy was carried out in three patients. Recurrence of active bleeding was found in two patients and a healed right-ventricular wound without active bleeding in one patient. Myocardial suture was performed through a sternotomy to repare a left-ventricular wound and through an anterolateral thoracotomy to control the left anterior descending coronary artery at the apex.Associated procedures were removal of a dagger under direct vision (n=1), removal of an intra-thoracic foreign body (n=1), Endo-GIA stapling of lung wounds (n=4), direct suturing of diaphragmatic wounds (n=1), and hemostasis of the intercostal artery (n=2). No deaths and no significant complications occurred in the immediate postoperative period or after follow-up at 3 months.Conclusions: Videothoracoscopic cardiac exploration appears to be an accurate and reliable method for diagnosing and treating thoracic wounds.

Journal of Cardiac SurgeryVolume 32, Issue 7 p. 418-419 IMAGES IN CARDIAC SURGERY Caseous calcification of the left aortic valve cusp Elie Dan Schouver MD, MSc, Elie Dan Schouver MD, MSc Department of Cardiology, CHU PASTEUR, Nice, FranceSearch for more papers by this authorDiane Lena MD, Diane Lena MD Department of Cardiac Surgery, Institut Arnault Tzanck, Saint Laurent du Var, FranceSearch for more papers by this authorGen Paul MD, Gen Paul MD Department of Radiology, Institut Arnault Tzanck, Saint Laurent du Var, FranceSearch for more papers by this authorAlain Mihoubi MD, Alain Mihoubi MD Department of Cardiac Surgery, Institut Arnault Tzanck, Saint Laurent du Var, FranceSearch for more papers by this authorStephane Lopez MD, MSc, Corresponding Author Stephane Lopez MD, MSc steflopez1@yahoo.fr orcid.org/0000-0001-5602-6697 Department of Cardiac Surgery, Institut Arnault Tzanck, Saint Laurent du Var, France Correspondence Stéphane Lopez MD, MSc, Institut Arnault Tzanck, Avenue du Docteur Maurice Donat, 06721 Saint Laurent du Var Cedex, France. Email: steflopez1@yahoo.frSearch for more papers by this author Elie Dan Schouver MD, MSc, Elie Dan Schouver MD, MSc Department of Cardiology, CHU PASTEUR, Nice, FranceSearch for more papers by this authorDiane Lena MD, Diane Lena MD Department of Cardiac Surgery, Institut Arnault Tzanck, Saint Laurent du Var, FranceSearch for more papers by this authorGen Paul MD, Gen Paul MD Department of Radiology, Institut Arnault Tzanck, Saint Laurent du Var, FranceSearch for more papers by this authorAlain Mihoubi MD, Alain Mihoubi MD Department of Cardiac Surgery, Institut Arnault Tzanck, Saint Laurent du Var, FranceSearch for more papers by this authorStephane Lopez MD, MSc, Corresponding Author Stephane Lopez MD, MSc steflopez1@yahoo.fr orcid.org/0000-0001-5602-6697 Department of Cardiac Surgery, Institut Arnault Tzanck, Saint Laurent du Var, France Correspondence Stéphane Lopez MD, MSc, Institut Arnault Tzanck, Avenue du Docteur Maurice Donat, 06721 Saint Laurent du Var Cedex, France. Email: steflopez1@yahoo.frSearch for more papers by this author First published: 09 July 2017 https://doi.org/10.1111/jocs.13168Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume32, Issue7July 2017Pages 418-419 RelatedInformation

Objective: The study objective was to compare the 30-day outcomes of a standardized aortic valve repair technique (REPAIR group) associating root remodeling with an expansible aortic ring annuloplasty versus mechanical composite valve and graft (CVG group) replacement in treating aortic root aneurysms.Methods: A total of 261 consecutive patients with aortic root aneurysm were enrolled in this multicentric prospective cohort (131 in the CVG group, 130 in the REPAIR group) in 20 centers. The main end point is a composite criterion including mortality; reoperation; thromboembolic, hemorrhagic, or infectious events; and heart failure. Secondary end points were major adverse valve-related events. Crude and propensity score adjusted estimates are provided.Results: The mean age was 56.1 years, and the valve was bicuspid in 115 patients (44.7%). The median (interquartile range) preoperative aortic insufficiency grade was 2.0 (1.0-3.0) in the REPAIR group and 3.0 (2.0-3.0) in the CVG group (P = .0002). Thirty-day mortality was 3.8% (n = 5) in both groups (P = 1.00). Despite a learning curve and longer crossclamp times for valve repair (147.7 vs 99.8 minutes, P<.0001), the 2 groups did not differ significantly for the main criterion (odds ratio, 1.31; 95% confidence interval, 0.72-2.40; P = .38) or 30-day mortality (odds ratio, 0.99; 95% confidence interval, 0.28-3053; P = .99), with a trend toward more frequent major adverse valve-related events in the CVG group (odds ratio, 2.52; 95% confidence interval, 0.86-7.40; P = .09). At discharge, 121 patients (96.8%) in the REPAIR group had grade 0 or 1 aortic insufficiency.Conclusions: A new standardized approach to valve repair, combining an expansible aortic annuloplasty ring with the remodeling technique, presented similar 30-day results to mechanical CVG with a trend toward reducing major adverse valve-related events. Analysis of late outcomes is in process for 3- and 10-year follow-ups.

A wrapping procedure for acute type A aortic dissection was performed on six elderly patients at high risk for conventional surgery. Aortic valve insufficiency was mild, with no malperfusion syndrome. A Teflon plaque or Dacron vascular prosthesis was passed around the aorta and tightened from the coronary ostia to the innominate artery. No severe neurologic complications or deaths occurred in the postoperative period. Computed tomography and magnetic resonance imaging imaging during follow-up showed aortic diameters had stabilized in all patients.

Le thrombus aortique est une conséquence rare et représentant un danger vital des traumatismes aortiques. Nous rapportons le cas d'un jeune homme se présentant avec cette complication après un accident de véhicule à moteur, et chez qui un volumineux thrombus aortique a été identifié à l'isthme aortique par le scanner. La lésion a été initialement traitée avec de l'héparine, et un stent couvert secondaire a été employé pour un faux anévrysme de l'isthme aortique découvert secondairement.

Rupture of the membranous septum is a very rare complication of blunt chest trauma. In this report, we describe a 22-year-old man who sustained multiple blunt trauma injuries during a motor vehicle accident. Rupture of the membranous septum was diagnosed 48 hours after the initial trauma and the defect was closed with Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ). However, the operation was complicated by complete atrioventricular block requiring implantation of a permanent DDD pacemaker. (Ann Thorac Surg 2011; 91: e3-4) (C) 2011 by The Society of Thoracic Surgeons

Aortic thrombus is a rare and a life-threatening consequence of aortic trauma. We report the case of a young man presenting with this complication after a motor vehicle accident, and in whom a large aortic thrombus was identified at the aortic isthmus by computed tomography of the chest. The lesion was treated initially with heparin, and a delayed covered stent was used for a false aneurysm of the aortic isthmus that was discovered secondarily.

The impact of meteorological conditions on the occurrence of various cardiovascular events has been reported. The aim of this work was to study the correlations between weather conditions and the occurrence of type A acute aortic dissections (AADs). Between 1997 and 2007, all the medical records of patients who underwent surgery for type A AADs in Toulouse University Hospital (France) were reviewed. The clinical data were confronted with the meteorological data provided by the French national meteorological office (MétéoFrance) over the same period. Two hundred and six patients with spontaneous type A AADs underwent surgery during this period. The incidence of aortic dissection was higher in winter time than in summer (P=0.018). The days with aortic dissections were colder than those without aortic dissections (P=0.017). Statistical analysis highlighted a decrease of atmospheric temperature during the three days preceding the upset of the symptoms (P=0.0009). This work demonstrates a correlation between spontaneous type A AADs and low atmospheric temperature.

Objective: We suggest standardizing aortic valve repair using a physiologic approach by associating root remodeling with resuspension of the cusp effective height and external subvalvular aortic ring annuloplasty.Methods: A total of 187 patients underwent remodeling associated with subvalvular aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated: group 1, gross visual estimation (74 patients); group 2, alignment of cusp free edges (62 patients); and group 3, 2-step approach, alignment of the cusp free edges and effective height resuspension (51 patients). The composite outcome was defined as recurrence of aortic insufficiency of grade 2 or greater and/or reoperation.Results: The operative mortality rate was 3.2% (n = 6). Treatment of a cusp lesion was most frequently performed in group 3 (70.6% vs 20.3% in group 1 and 30.6% in group 2, P < .001). Nine patients required reoperation during a follow-up period of 24 months (range, 12-45), 6 patients in group 1 and 3 patients in group 2. At 1 year, no patients in group 3 presented with composite outcome events compared with 28.1% in group 1 and 15% in group 2 (P < .001). Residual aortic insufficiency and tricuspid anatomy were independent risk factors for the composite outcome in groups 1 and 2. The annulus diameter, the presence of Marfan syndrome, and cusp repair had no effect on aortic insufficiency recurrence or reoperation.Conclusions: A standardized and physiologic approach to aortic valve repair, considering both the aorta (root remodeling) and the valve (resuspension of the cusp effective height and subvalvular ring annuloplasty) improved the preliminary results and might affect their long-term durability. The ongoing Conservative Aortic Valve Surgery for Aortic Insufficiency and Aneurysm of the Aortic Root (CAVIAAR) trial will compare this strategy to mechanical valve replacement. (J Thorac Cardiovasc Surg 2010;140:S28-35)

Aortic valve sparing is gaining increasing acceptance, however association with cusp repair may jeopardize its results. We studied patients operated electively with a standardized valve sparing approach with or without additional cusp repair. 125 patients with aortic root aneurysms underwent the Remodeling technique combined with a subvalvular annuloplasty in 10 centers (16 surgeons). Patients were analysed prospectively in 2 groups: without cusp repair (group 1, n=80) and with cusp repair (group 2, n=45) using plicating stitches (33), and/or running suture (10), and/or median raphe resection (12). Despite more severe preoperative aortic insufficiency (AI) in group 2, reoperation rate was not significantly higher (table). Five over 6 reoperations occurred during early experience. Cusp repair rate increased from 22.3% (15) in early period to 53.4% (27, p<0.01) since 2007, when aggressive management of cusp prolapse was started combining cusp free edges alignment with effective height measurement.Empty CellGroup 1 without cusp repairGroup 2 with cusp repairMarfan16 (20%)2 (4.4%)*Bicuspid valves7 (8.8%)19 (42.2%)*Preoperative AI grade1.66±1.2 (0-4)2.42±1.2 (0-4)*Preoperative annulus diameter (mm)27.5±1.6 (23-30)28.6±2.1 (24-36)*Operative mortality4 (5%)1 (2.2%)Postoperative annulus diameter (mm)20.1±2.1 (17-25)21.3±1.1 (16-25)*Post-operative AI grade0.3±0.4 (0-1)0.2±0.4 (0-1)Mean follow-up (months)36.1±21 (1-69)17.5±16.9 (1-66)*Freedom from AI≥grade 264 (94.1%)37 (92.5%)Reoperation for valve replacement4 (5%)2 (4.4%)Survival72 (97.3%)42 (95.5%)*p<0.05 p<0.05 Additional cusp repair does not affect early results of aortic valve sparing. Standardized management of root remodeling, cusp repair and aortic annuloplasty may improve feasibility and long term outcomes. This approach is currently evaluated versus mechanical valve replacement by CAVIAAR trial (Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysms of the Aortic Root).

Les syndromes aortiques aigus regroupent trois entites : la dissection aortique, l’hematome intramural et l’ulcere atherosclereux penetrant. En raison du risque vital, le diagnostic et la prise en charge doivent etre realises rapidement avec la technique la plus fiable et la moins invasive possible. Une imagerie complementaire est indispensable, elle aura plusieurs objectifs : une description precise des lesions, une classification topographique, une recherche d’extension aux troncs supra-aortiques et aux arteres viscerales, ou une atteinte des structures voisines (pericarde, plevre, mediastin). Ce bilan exhaustif permet d’evaluer la severite et le potentiel evolutif des lesions et ainsi guider la strategie therapeutique. Le scanner permet actuellement au mieux le bilan des lesions en urgence, en revanche, il n’apporte pas d’information sur l’etat de la valve aortique. L’echocardiographie a l’avantage d’etre disponible et realisable au lit du patient, dans les unites de soins intensifs, mais elle n’est pas toujours contributive. Cet examen permet en revanche l’evaluation de la fonction ventriculaire, la recherche d’une insuffisance aortique ou d’un epanchement. En fait, ces deux examens sont souvent complementaires. Un traitement medical et une surveillance en reanimation sont indispensables dans tous les cas. En dehors du traitement medical, schematiquement, pour les atteintes de l’aorte ascendante, une intervention chirurgicale en urgence reste la regle, parfois associee a un geste endovasculaire, en particulier en cas de malperfusion viscerale. Pour les dissections de type B, les traitements chirurgicaux ou endovasculaires sont reserves aux complications, dominees par la rupture et les ischemies viscerales. Dans ce cas, les techniques endovasculaires se sont developpees du fait de leur meilleure tolerance. 1) L’exclusion des portes d’entrees par un stent-graft permet la depressurisation du faux chenal et la thrombose de celui-ci. Un remodelage avec une diminution des diametres aortiques est ainsi observe avec une reperfusion des arteres distales. 2) La fenestration par voie endovasculaire est reservee aux malperfusions liees a un mecanisme dynamique. Le principe est de creer un orifice de communication large entre le vrai et le faux chenal pour faire baisser la pression dans le faux chenal. 3) La mise en place de stents non couverts dans les arteres d’organes concernes par la malperfusion peut etre utile pour les ischemies d’origine statique. Au total, les dissections aortiques peuvent beneficier de therapeutiques endovasculaires efficaces, soit isolement, soit en complement d’une chirurgie de l’aorte ascendante.

The acute aortic syndromes comprise three entities: aortic dissection, intramural haematoma and penetrating atherosclerotic ulcer. The life-threatening nature of these conditions requires that diagnosis and treatment be rapid with the most reliable and least invasive technique possible. Imaging methods are essential with several objectives; accurate description of the lesions, topographical classification, investigation of the extent of the lesions to the supra-aortic and visceral arteries or of involvement of adjacent structures such as the pericardium, the pleural or mediastinal cavities. These extensive investigations provide an evaluation of the severity and potential for progression of the lesions and a guide to treatment. The CT scan is the best method of investigation in an emergency but it does report the state of the aortic valve. Echocardiography has the advantage of being widely available and can be performed at the bedside in the intensive care unit but it is not always informative. However, this technique allows evaluation of left ventricular function, exclusion of the diagnosis of cardiac failure or pericardial effusion. In practice, the two investigations are often complementary. Treatment and surveillance in the intensive care unit are essential in all cases. Besides medical therapy, schematically, ascending aortic lesions require emergency surgery as a rule, sometimes associated with an endovascular procedure especially in cases with abnormal perfusion of viscera. In type B aortic dissection, surgery and endovascular procedures are reserved for complications, principally rupture and visceral ischaemia. In these cases, endovascular techniques have progressed because of their better tolerance. Exclusion of the proximal intimal tear by a stent-graft depressurises the false lumen and predisposes to its thrombosis. Remodelling with reduction of the aortic diameter is observed with reperfusion of the distal vessels. Endovascular fenestration is reserved for problems of perfusion due to a dynamic mechanism. The principle is to create a wide orifice between the true and false lumens in order to reduce pressure in the false lumen. The implantation of bare stents may be useful in the arteries of viscera with ischaemia by a static mechanism. In conclusion, aortic dissection may be treated effectively by endovascular techniques, either alone or as a complement to surgery of the ascending aorta.