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BACKGROUND: An 89-year-old male with heart failure due to severe aortic stenosis and chronic renal failure was scheduled for transcatheter aortic valve implantation (TAVI). INVESTIGATION: The day before the procedure the patient underwent an echocardiogram (as per in-house pre-procedural protocol). A large mobile thrombus was discovered at the left ventricular apex, and the TAVI procedure was cancelled. DIAGNOSIS: Severe calcific aortic stenosis with a large mobile intracavitary thrombus. MANAGEMENT: As the patient presented four weeks later with worsening symptoms of acute heart failure and could not be weaned from intravenous furosemide, the Heart Team decided to proceed with TAVI, trying to minimise wire manipulations throughout the procedure. An Evolut R system was implanted with no complications. Three days after the procedure, the patient was off intravenous diuretics and able to walk around the ward. © Europa Digital & Publishing 2017. All rights reserved.

Objective: To investigate the alterations of structure and mechanical properties of the aortic wall, resulting from impairment of vasa vasorum Row. Methods: Eight healthy Landrace pigs were subjected to interruption of vasa vasorum how to the upper segment of their descending thoracic aorta. Under sterile conditions, the periaortic tissue was excised and the contiguous intercostal arteries were ligated. Ten sham-operated pigs were used as controls. Fifteen days postoperatively, the animals were sacrificed and their upper descending thoracic aortas were removed. Histology, and collagen and elastin content determination by image analysis technique were performed. Mechanical analysis of aortic strips was carried out with a uniaxial tension device and stress-strain curves were obtained. Results: In contrast to normal aortic walls of the control group, histology of the avascular aortas revealed severe ischemic necrosis of the outer media along with abnormal straightening of the elastin and collagen fibers, without significant collagen and elastin content changes. The borderline between the outer ischemic and inner non-ischemic media was sharp, and an outset of dissection was observed at this point. Mechanical analysis showed that at the same level of strain, the ischemic aorta was significantly stiffer at both low (P = 0.03) and high strains (P = 0.003). Conclusions: Impairment of blood supply to the thoracic aorta leads to abnormal morphology of elastin and collagen fibers of the outer media, resulting in increased aortic stiffness under a wide range of stresses. In the clinical setting, decreased vasa vasorum flew, reportedly occurring in arterial hypertension, may increase the stiffness of the outer media of the thoracic aorta and produce interlaminar shear stresses, contributing to the development of aortic dissection. (C) 2000 Elsevier Science B.V. All rights reserved.