A 21-year-old male patient presented with a typical middle aortic syndrome. Echography disclosed a severe narrowing of the lower thoracic aorta with parietal thickening. The isolated character of the lesion was confirmed by magnetic resonance imaging and aortography. The surgical cure was realized by a Dacron bypass between the upper thoracic descending aorta and the juxta-diaphragmatic thoracic aorta. Aortic biopsy confirmed Takayasu's disease. Postoperative course was uneventful with normalized blood pressure. The therapeutic options, surgery versus percutaneous dilatation and stent, are discussed.

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Summary: Endocarditis at the aortic level is usually characterized by the presence of a vegetation or an abscess on echocardiography. This paper reports on what is believed by the authors to be the first case of endocarditis presenting as an aneurysmal deformation of one aortic cusp without a vegetation. Key words: aneurysmal deformation of the aortic valve, endocardi tis Case ReportA 63-year-old man was admitted for fever and alteration of consciousness. He had presented with a left otitis with mastoiditis several months before. He was well until a few hours before when confusion and obtundation developed. The patient had no cardiovascular history.On admission, temperature was 40°C and cardiopulmonary examination was unremarkable. Bilateral hyporeflexia and stiffness of the neck were observed. White cell count was 23,400 per mm3 and C reactive protein was 16 mg/dl. A computed tomographic scan of the head revealed pansinusitis. Ampicillin and ceftazidime were initiated. On the day after admission, the patient was stuporous and the temperature was 38°C. Cerebrospinal fluid examination as well as blood cul- tures grew Streptococcus pneumoniae. Penicillin was administered. After 2 weeks of progressive recovery, the fever rose again to 38"C, without meningeal signs. A diastolic murmur was heard at the aortic area. Transthoracic echocardiography showed a large aneurysm of the left coronary cusp, without evidence for a vegetation. There was a regurgitant aortic flow graded 4/4 associated with a small diastolic mitral regurgitation, consistent with severe regurgitation. The left ventricle end-diastolic dimension was 55 mm. Transesophageal echocardiographic examination confirmed this unusual presentation of aortic endocarditis (Fig. l), and disclosed two regutgitantjets.The patient underwent urgent aortic valve replacement. The surgeon confirmed the echocardiographic findings. with marked enlargement of the left coronary cusp prolapsing into the left ventricular outflow tract, and with a perforation. Microbiological examination of the explantated valve was sterile. Antibiotics were discontinued after 6 weeks and the sub sequent course was uneventful. DiscussionOf patients with native valve endocarditis, 20 to 40% do not have an identifiable predisposing cardiac lesion, and approximately half of the cases are located at the aortic valve level. ' Various lesions may occur during the course of aortic valve endocarditis. It may present as vegetations, with or without perforations. Aortic abscess may present as an echo-free space adjacent to the aortic root. When disruption of the aortic valve occurs, echoes from the aortic valve can be seen protruding into the left ventricular outflow tract during diasto1e.l Transthoracic and transesophageal echocardiography allowed us to demonstrate an isolated aortic cusp aneurysmal deformation, with two perforations leading to severe aortic regurgitation. To our knowledge, the present case is the first to demonstrate such an aortic involvement, namely, a cusp aneurysm as the complicati...

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