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Nishino S, Nishimura M, Asada Y, Yamashita A, Shibata Y. Progressive worsening of aortic regurgitation due to detachment of the aortic valve commissure with multimodality imaging to elucidate pathogenesis: a case report. Eur Heart J Case Rep 2024; 8:ytae178. [PMID: 38651082 PMCID: PMC11033951 DOI: 10.1093/ehjcr/ytae178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 03/26/2024] [Accepted: 04/07/2024] [Indexed: 04/25/2024]
Abstract
Background Aortic regurgitation (AR) associated with detachment of the aortic valve commissure is extremely rare. We present a case of progressively worsening severe chronic AR due to detachment of the aortic valve commissure during hospitalization that was confirmed with multimodality imaging. Case summary A 50-year-old male with Marfan syndrome visited our hospital to receive treatment for cholelithiasis. Pre-operative examination revealed severe AR and aortic root aneurysm. Because the patient was asymptomatic, it was decided that cholecystectomy should be performed first. However, the patient's heart failure worsened acutely when his blood pressure increased just before induction of anaesthesia. The patient required intubation and management of heart failure. Five days later, the patient underwent cholecystectomy. He was treated for heart failure and underwent open heart surgery on the 35th hospital day. Intraoperative transoesophageal echocardiography revealed that his AR was caused by both enlargement of the aortic root and localized dissection of the aortic valve commissure, which was supported by intraoperative findings and histopathological evaluation. Aortic regurgitation was exacerbated by a new localized dissection, resulting in acute worsening of heart failure. Discussion Aortic valve commissure detachment can easily lead to sudden onset of severe AR, deteriorating haemodynamics, and acute pulmonary oedema. Since delayed medical treatment leads to poor clinical outcomes, prompt and accurate diagnosis and appropriately timed surgical intervention are essential. This very rare case of severe AR worsening due to spontaneous aortic valve commissure dissection was evaluated with multiple modalities during hospitalization. Understanding this clinical condition will help cardiologists provide better medical care.
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Affiliation(s)
- Shun Nishino
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center, 1173 Arita, Miyazaki 880-2102, Japan
| | - Masanori Nishimura
- Department of Cardiothoracic Surgery, Miyazaki Medical Association Hospital Cardiovascular Center, Miyazaki, Japan
| | - Yujiro Asada
- Department of Pathology, Miyazaki Medical Association Hospital Cardiovascular Center, Miyazaki, Japan
| | - Atsushi Yamashita
- Department of Pathology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yoshisato Shibata
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center, 1173 Arita, Miyazaki 880-2102, Japan
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Huntley GD, Bird JG, Lo YC, Bagameri G, Michelena HI. Raphal Cord Rupture: A Rare Mechanism of Aortic Regurgitation in Bicuspid Aortic Valve. JACC Case Rep 2023; 11:101791. [PMID: 37077439 PMCID: PMC10107042 DOI: 10.1016/j.jaccas.2023.101791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 04/21/2023]
Abstract
A 70-year-old male with chronic aortic regurgitation was referred with abrupt worsening heart failure. Late referral markers were pulmonary hypertension, mitral regurgitation, and tricuspid regurgitation. Evaluation revealed rupture of a raphal cord or fenestrated raphe from the conjoined cusp of a congenitally bicuspid aortic valve, a rare mechanism of aortic regurgitation. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Geoffrey D. Huntley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jared G. Bird
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ying-Chun Lo
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector I. Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Address for correspondence: Dr Hector I. Michelena, Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA. @michelenahector
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3
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Abstract
Background: Aortic valve fenestrations (AVFs) seem to be relatively common; however, their impact in human heart disease is not entirely clear. Methods: A review was carried out to assess all scientific literature on human patients related to AVFs, as described in the published literature. The search was conducted on 2 different databases, Medline (PubMed), and ISI Web of Knowledge. Results: Fifty-five reports were under analysis. Autopsy studies showed AVFs to be present in 55.9% of individuals studied in such studies. They occur more frequently in men and, in general, their frequency increases with age. Although common, fenestrations rarely cause regurgitation; however, they may play an important role in the pathophysiology of some cases of severe aortic regurgitation. AVFs have been described in patients with Down syndrome and Marfan syndrome, in patients with bicuspid or quadricuspid valves, and in patients with myxomatous valvular degeneration. Echocardiographic assessment of aortic regurgitation seems to have limitations in the diagnosis of valvular fenestrations. Conclusions: Fenestrations of the aortic valve are very common and are associated with certain clinical conditions. It is unknown if AVFs play any role in the current epidemic of aortic valve disease. Future studies should aim to better define the role of AVFs in aortic valve disease, to further understand its etiology and to develop diagnostic criteria.
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Chang RY, Chen CC, Hsu WP, Hsiao PC, Tsai HL, Hsiao PG, Wu JD, Guo HR. Nontraumatic avulsion of aortic valve commissure as a cause of acute aortic valve regurgitation: A case report. Medicine (Baltimore) 2016; 95:e5053. [PMID: 27749570 PMCID: PMC5059073 DOI: 10.1097/md.0000000000005053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Avulsion of the aortic valve commissure as a cause of acute aortic valve regurgitation is mostly due to trauma, infective endocarditis, or ascending aortic dissection. Nontraumatic avulsion of the aortic valve commissure is very rare. We reviewed the literature and analyzed potential risk factors of nontraumatic avulsion. CASE PRESENTATION An 80-year-old male with hypertension was seen in the emergency department with acute onset dyspnea. Echocardiogram revealed left ventricular hypertrophy with adequate systolic function, prolapse of the noncoronary cusp, and incomplete coaptation of the right coronary and noncoronary cusps with severe aortic valve regurgitation. Surgery revealed an avulsion between the left coronary and noncoronary cusps. Histopathology examination of the aortic valve showed myxoid degeneration, fibrosis, and calcification. Examination of the ascending aorta revealed myxoid degeneration and fragmentation of elastic fibers. Aortic valve replacement was performed, and the patient was alive and well 4 years after surgery. A review of the literature showed that more than three-fourths of the similar cases occurred in males, and about half in patients with hypertension and those 60 years of age or older. CONCLUSIONS In the case of acute aortic regurgitation without a history of trauma, infection, or valvotomy, when 2 prolapsed aortic cusps are observed by echocardiography in the absence of an intimal tear of the ascending aorta, an avulsion of the aortic commissure should be suspected, especially in males with hypertension who are 60 years of age or older.
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Affiliation(s)
- Rei-Yeuh Chang
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi
- Department of Beauty and Health Care, Min-Hwei Junior College of Health Care Management, Tainan
- Department of Nursing, Chung-Jen Junior College of Nursing, Health Sciences and Management
| | - Chien-Chang Chen
- Division of Cardiovascular Surgery, Department of Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi
| | - Wei-Pang Hsu
- Division of Family Medicine, Cheng Ching General Hospital
| | - Pei-Ching Hsiao
- Division of Hematology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung
| | - Han-Lin Tsai
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi
| | - Ping-Gune Hsiao
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi
| | - Jiann-Der Wu
- Department of Pathology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi
| | - How-Ran Guo
- Department of Occupational and Environmental Medicine, National Cheng Kung University and Hospital, Tainan, Taiwan
- Correspondence: How-Ran Guo, Department of Occupational and Environmental Medicine, National Cheng Kung University, 138 Sheng-Li Road, Tainan 70428, Taiwan (e-mail: )
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5
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Abstract
Acute aortic regurgitation usually results from infective endocarditis, but is also caused by aortic dissection and trauma to the heart. Most of the left ventricular stroke volume is regurgitated back into the left ventricle; thus, the forward stroke volume to the body and the cardiac output may be severely compromised. An acute increase in left ventricular end-diastolic volume results in a marked increase in left ventricular end-diastolic pressure, and the mitral valve usually closes prematurely. Compensatory tachycardia is the rule and helps to shorten diastole; thus, the time available for aortic regurgitation to occur is reduced, and the cardiac output is often maintained. On physical examination, there is tachycardia; the peripheral arterial pulse shows a rapid rise, but the systolic pressure is normal; the diastolic pressure is normal or even reduced; and the pulse pressure is often normal. The electrocardiogram (ECG) may be normal except for sinus tachycardia and often for nonspecific ST-T changes. The chest roentgenogram usually shows signs of pulmonary venous hypertension or even pulmonary edema. Echocardiography may show vegetations on the aortic valve, prolapse of an aortic leaflet into the left ventricle, and premature mitral valve closure. Doppler echocardiography is useful in detecting the presence of aortic regurgitation. In cases of infective endocarditis, the appropriate antibiotic therapy must be given. Aortic regurgitation due to dissection of the aorta is usually an indication for surgery. In patients with severe aortic regurgitation, available medical therapy includes digitalis, diuretics, and vasodilators. When patients respond dramatically to the use of digitalis, diuretics, and arterial dilators, surgical therapy can be delayed until heart failure and infection are controlled and the patient is more stable. If the patient does not respond immediately and dramatically to therapy, then valve replacement should not be delayed, even if the infection is uncontrolled or the patient has had little antibiotic therapy.
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Affiliation(s)
- Robert A. O'Rourke
- From The Division of Cardiology, Department of Medicine, University of Texas, Health Science Center, San Antonio, TX 78284
| | - Richard A. Walsh
- From The Division of Cardiology, Department of Medicine, University of Texas, Health Science Center, San Antonio, TX 78284
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6
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Anomalous Cord From the Raphe of a Congenitally Bicuspid Aortic Valve to the Aortic Wall Producing Either Acute or Chronic Aortic Regurgitation. J Am Coll Cardiol 2014; 63:153-7. [DOI: 10.1016/j.jacc.2013.09.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Revised: 08/30/2013] [Accepted: 09/10/2013] [Indexed: 11/15/2022]
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7
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Yamasaki M, Watanabe S, Abe K, Kawazoe K. Commissure avulsion of the aortic valve caused by purulent pericarditis: report of a case. Surg Today 2013; 44:1343-5. [PMID: 23720146 DOI: 10.1007/s00595-013-0624-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 12/17/2012] [Indexed: 11/24/2022]
Abstract
A 20-year-old man with fever and chest pain was referred to our hospital, where purulent pericarditis was confirmed by various examinations. Hemodynamic collapse and acute pulmonary edema occurred 1 week later, caused by acute severe aortic valvular regurgitation (AR). Emergency surgery revealed that the AR had been caused by avulsion of the aortic valvular commissure, which seemed to have resulted from penetration of the pericardial inflammatory process to the aortic root. We report this case because purulent pericarditis is now relatively uncommon and resultant aortic commissure avulsion is even rarer.
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Affiliation(s)
- Manabu Yamasaki
- Department of Cardiovascular Surgery, St. Luke's International Hospital, 9-1 Akashicho, Chuoku, Tokyo, 104-8560, Japan,
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8
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Ajithdoss DK, Arenas-Gamboa AM, Edwards JF. A fibrous band associated with the non-coronary aortic valve cusp in a dog. J Vet Cardiol 2011; 13:127-9. [PMID: 21641896 DOI: 10.1016/j.jvc.2011.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 01/12/2011] [Accepted: 01/12/2011] [Indexed: 11/16/2022]
Abstract
A fibrous band connecting the middle of the free edge (nodulus Arantii) of the non-coronary aortic valve cusp to the ascending aorta just above the level of the non-coronary sinus of Valsalva was observed in an asymptomatic, 11-year-old, male Border Collie. The fibrous band was unrelated to the cause of the death in this dog. Such fibrous bands are usually reported in humans with congenital bicuspid aortic valves. To our knowledge, this is the first report of a fibrous band in the aortic valve in a domestic animal.
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Affiliation(s)
- Dharani K Ajithdoss
- Department of Veterinary Pathobiology, College of Veterinary Medicine and, Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA.
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9
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Kazuya A, Jun H, Naohito T, Kazuma M, Yutaka K. Echocardiographic and surgical findings of spontaneous avulsion of the aortic valve commissure. Circ J 2004; 68:254-6. [PMID: 14993782 DOI: 10.1253/circj.68.254] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Spontaneous detachment of the aortic valve commissure (ie, avulsion of a commissure) is a rare cause of acute massive aortic regurgitation that follows a rapidly deteriorating clinical course. The aortic valve commissure between the non-coronary and right coronary cusps detached from the aortic wall in a 79-year old man with ascending aortic aneurysm. Emergency aortic valve replacement and aneurysmoplasty were successfully performed; histopathology of the aorta and aortic valve showed cystic medial necrosis and myxomatous degeneration, respectively. Preoperative transthoracic echocardiography showed an eccentric massive regurgitant jet at the site of the prolapsing cusps with a vegetation-like echodense mass, and transesophageal echocardiography showed the prolapsing non-coronary and right coronary cusps conjoined by the commissural tissue. It was the precise echocardiographic evaluation of the avulsion that enabled sucessful emergency aortic valve surgery.
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Affiliation(s)
- Akiyama Kazuya
- Department of Cardiovascular Surgery, Iwaki Kyoritsu General Hospital, Japan
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10
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Akiyama K, Taniyasu N, Iba Y, Hirota J, Asano S. Sudden deterioration of aortic regurgitation due to rupture of a raphal cord on the conjoined cusp. JAPANESE CIRCULATION JOURNAL 2000; 64:477-80. [PMID: 10875743 DOI: 10.1253/jcj.64.477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 57-year-old man was admitted to hospital for acute myocardial infarction associated with mild aortic regurgitation, which was successfully treated by intracoronary thrombolysis. Twenty-four days later, he suffered from another chest pain attack without any electrocardiographic ST-T changes. The coronary angiogram did not show any significant lesions, but the aortic root angiogram showed massive aortic regurgitation. Surgery revealed a bicuspid aortic valve with a conjoined cusp that had a fenestrated raphe torn away from the aortic wall and prolapsing into the left ventricle. The aortic valve was successfully replaced with a St Jude Medical mechanical valve prosthesis. The pathological significance of the intact raphal cord and the rupture remains an unsolved problem. This is the first reported case in which an increase of aortic regurgitation due to a ruptured raphal cord supporting the conjoined cusp was confirmed by a serial root angiogram.
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Affiliation(s)
- K Akiyama
- Department of Cardiovascular Surgery, Iwaki Kyoritsu General Hospital, Fukushima, Japan
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11
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Sakakibara Y, Gomi S, Mihara W, Mitsui T, Unno H, Doi T. Acute heart failure due to local dehiscence of aortic wall at aortic valvular commissure. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2000; 48:80-2. [PMID: 10714027 DOI: 10.1007/bf03218091] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Spontaneous dehiscence of the aortic wall at the aortic commissure is not recognized as one of the usual pathological causes of aortic regurgitation. We describe the case of a 56-year-old man with hypertension, who experienced acutely progressive congestive heart failure due to massive aortic regurgitation. Local layer dehiscence around the commissure was noted with partial detachment of the commissure resulting in the loss of commissural support with secondary rupture of a non-coronary cusp, which led to massive aortic regurgitation.
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Affiliation(s)
- Y Sakakibara
- Department of Surgery, University of Tsukuba, Ibaraki, Japan
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12
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Blaszyk H, Witkiewicz AJ, Edwards WD. Acute aortic regurgitation due to spontaneous rupture of a fenestrated cusp: report in a 65-year-old man and review of seven additional cases. Cardiovasc Pathol 1999; 8:213-6. [PMID: 10724525 DOI: 10.1016/s1054-8807(99)00009-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
A 65-year-old man with chronic hypertension developed dyspnea, a cough, and a new diastolic murmur. Two-dimensional echocardiography showed severe aortic regurgitation. No valvular vegetations were identified and blood cultures were negative. Surgical intervention was recommended, but the patient died of an acute intracranial hemorrhage two weeks later. At autopsy, the posterior aortic cusp was flail, due to rupture of the residual cord above two large fenestrations. There was no acute or healed endocarditis. To our knowledge, this is the eighth reported case of aortic valve incompetence due to spontaneous rupture of a fenestrated cusp. Patients ranged in age from 31-67 years (mean, 54), and 4 (50%) were older than 60 years. Seven (88%) of the 8 were men, and 4 (57%) of 7 had chronic hypertension. Analogously, in another four reported cases, aortic insufficiency developed following spontaneous rupture of the fenestrated raphe of an atypical congenitally bicuspid aortic valve. Noninfective and nontraumatic rupture of cord-like aortic valve structures may result in severe acute aortic regurgitation, particularly in men with chronic hypertension.
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Affiliation(s)
- H Blaszyk
- Department of Laboratory Medicine and Pathology, Mayo Clinic Foundation, Rochester, Minnesota 55905, USA
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13
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Yeo TC, Ling LH, Ng WL, Chia BL. Spontaneous aortic laceration causing flail aortic valve and acute aortic regurgitation. J Am Soc Echocardiogr 1999; 12:76-8. [PMID: 9882782 DOI: 10.1016/s0894-7317(99)70176-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Spontaneous laceration of the aorta is an unusual cause of flail aortic valve. We report a case of acute aortic regurgitation caused by flail aortic valve as a result of spontaneous laceration of the ascending aorta. The role of transesophageal echocardiography in the diagnosis of this condition is discussed.
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Affiliation(s)
- T C Yeo
- Cardiac Department, National University of Singapore
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14
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Bharani A, Mulye R, Bhargava KD. Isolated aortic valve prolapse due to cuspal inequality causing aortic regurgitation. Indian J Pediatr 1994; 61:588-90. [PMID: 7744463 DOI: 10.1007/bf02751727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- A Bharani
- Department of Medicine, M.G.M. Medical College, Indore
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15
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Agozzino L, de Vivo F, Falco A, de Luca L, Schinosa T, Cotrufo M. Surgical pathology of the aortic valve: gross and histological findings in 1120 excised valves. Cardiovasc Pathol 1994; 3:155-61. [DOI: 10.1016/1054-8807(94)90024-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/1993] [Accepted: 12/29/1993] [Indexed: 11/30/2022] Open
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16
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Agozzino L, de Vivo F, Falco A, de Luca Tupputi Schinosa L, Cotrufo M. Non-inflammatory aortic root disease and floppy aortic valve as cause of isolated regurgitation: a clinico-morphologic study. Int J Cardiol 1994; 45:129-34. [PMID: 7960251 DOI: 10.1016/0167-5273(94)90268-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A clinico-morphologic study was performed on 1120 patients who underwent aortic valve replacement at the Department of Medical and Surgical Cardiology, 2nd University Medical School of Naples, Naples, Italy, from January 1981 through December 1991. In 69 cases the aortic valve was incompetent due to a non-inflammatory aortic root disease such as myxomatous infiltration of the cusps and or aortic root dilatation. Among these patients males were prevalent (male/female ratio = 2.2). The mean age was 37 +/- 7.5 years. A floppy mitral valve was diagnosed in 16 cases while in one a left atrial myxoma was found. The patients were divided into 3 groups: Group 1-29 patients with aortic root dilatation and normal cusps; Group 2-25 patients with aortic root dilatation and myxomatous infiltration of aortic cusps (floppy aortic valve); and Group 3-15 patients with floppy aortic valve and undilated aortic root. At the gross examination the cusps of the patients in Groups 2 and 3 were redundant, thin, soft and gelatinous. The histology showed myxomatous infiltration with disruption of the fibrous layer. In patients with aortic root dilatation the histology of the aortic root fragments showed a cystic medial necrosis. Deep correlation was found between the root dilatation and the grade of aortic wall cystic medial necrosis. Cusp's diastasis was the cause of aortic regurgitation in patients with aortic root dilatation, while cusp prolapse caused aortic incompetence in presence of the floppy aortic valve and undilated aortic root.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- L Agozzino
- Institute of Pathology, University Medical School, 2nd University of Naples, Italy
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17
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Kai H, Koyanagi S, Takeshita A. Aortic valve prolapse with aortic regurgitation assessed by Doppler color-flow echocardiography. Am Heart J 1992; 124:1297-304. [PMID: 1442499 DOI: 10.1016/0002-8703(92)90415-r] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The incidence of and the Doppler color-flow echocardiographic characteristics of aortic valve prolapse with nonrheumatic aortic regurgitation were examined. Aortic valve prolapse was observed in 21 of 243 patients (15 men and 6 women) with aortic regurgitation as detected by Doppler color-flow echocardiography (rheumatic, 112; nonrheumatic, 131) in 1247 consecutive patients. Patients with aortic valve prolapse included three patients with essential hypertension and one with annuloaortic ectasia. The remaining 17 patients (7% of those with aortic regurgitation) had no other associated cardiovascular disease (idiopathic aortic valve prolapse). Prolapse of the mitral or the tricuspid valve or both was associated with aortic valve prolapse in seven patients. Aortic regurgitation jet was markedly deviated from the axis of left ventricular outflow tract toward the anterior mitral leaflet or the interventricular septum in 17 of 21 (81%) patients with aortic valve prolapse, whereas 28 of 110 (25%) patients with nonrheumatic aortic regurgitation without prolapse and 17 of 112 (15%) patients with rheumatic aortic regurgitation without prolapse showed the deviation of regurgitant jet (p < 0.001). In conclusion, idiopathic aortic valve prolapse is one of the significant causes of aortic regurgitation, and a marked deviation of regurgitant jet is a characteristic Doppler color-flow echocardiographic finding of aortic regurgitation that results from aortic valve prolapse.
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Affiliation(s)
- H Kai
- Research Institute of Angiocardiology, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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18
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Abstract
A 22 year old man with Marfan's syndrome died suddenly following acute aortic valve prolapse. Although aortic root involvement in Marfan's syndrome is common, we have found no previous description of this particular complication in the literature.
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Affiliation(s)
- N J Carr
- RAF Institute of Pathology and Tropical Medicine, Halton, Aylesbury, Bucks, UK
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19
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Waller BF, Taliercio CP, Dickos DK, Howard J, Adlam JH, Jolly W. Rare or unusual causes of chronic, isolated, pure aortic regurgitation. Clin Cardiol 1990; 13:577-81. [PMID: 2397620 DOI: 10.1002/clc.4960130812] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Six patients undergoing aortic valve replacement had rare or unusual causes of isolated, pure aortic regurgitation. Two patients had congenitally bicuspid aortic valves with a false commissure (raphe) displaced to the aortic wall ("tethered bicuspid aortic valve"), two had floppy aortic valves, one had a congenital quadricuspid valve, and one had radiation-induced valve damage.
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Affiliation(s)
- B F Waller
- Nasser, Smith & Pinkerton Cardiology, Inc., Indianapolis, Indiana
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20
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Shaddy RE, Boucek MM, Sturtevant JE, Ruttenberg HD, Orsmond GS. Gradient reduction, aortic valve regurgitation and prolapse after balloon aortic valvuloplasty in 32 consecutive patients with congenital aortic stenosis. J Am Coll Cardiol 1990; 16:451-6. [PMID: 2373823 DOI: 10.1016/0735-1097(90)90601-k] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
From 1986 to 1988, balloon aortic valvuloplasty was performed in 32 patients with congenital valvular aortic stenosis. The patients ranged in age from 2 days to 28 years (mean +/- SD 8.3 +/- 5.9). One balloon was used in 17 patients and two balloons were used in 15 patients. Immediately after valvuloplasty, peak systolic pressure gradient across the aortic valve decreased significantly from 77 +/- 27 to 23 +/- 16 mm Hg (p less than 0.01), a 70% reduction in gradient. At early follow-up study (4.1 +/- 3.3 months after valvuloplasty), there was a 48 +/- 20.5% reduction in gradient compared with that before valvuloplasty, and at late follow-up evaluation (19.2 +/- 5.6 months), a reduction in gradient of 40 +/- 29% persisted. Echocardiography showed evidence of significantly increased aortic regurgitation in 10 patients (31%) and aortic valve prolapse in 7 patients (22%). There was no correlation between the balloon/anulus ratio and the subsequent development of aortic regurgitation or prolapse. In fact, no patient who showed a significant increase in aortic regurgitation had had a balloon/anulus ratio greater than 100%. It is concluded that balloon aortic valvuloplasty effectively reduces peak systolic pressure gradient across the aortic valve in patients with congenital aortic stenosis. However, subsequent aortic regurgitation and prolapse occur in a significant number of patients, even if appropriate technique and a balloon size no greater than that of the aortic anulus are used.
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Affiliation(s)
- R E Shaddy
- Department of Pediatrics, University of Utah, Salt Lake City
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Abstract
Inherited abnormalities of connective tissue elements often cause changes in the structure and function of the cardiovascular system. Well-known heritable disorders of connective tissue in which cardiovascular abnormalities are prominent include the Marfan syndrome and the Ehlers-Danlos syndrome. Connective tissue abnormalities also occur without the associated features of a recognized syndrome. These include isolated valvular prolapse and anuloaortic ectasia. In this review, the cardiovascular features of connective tissue abnormalities--both the recognized syndromes and the isolated abnormalities--are described, important concepts in the diagnosis and treatment of these disorders are reviewed, and the classification of inherited connective tissue abnormalities of the cardiovascular system is discussed.
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Bellitti R, Caruso A, Festa M, Mazzei V, Iesu S, Falco A, Cotrufo M, Agozzino L. Prolapse of the "floppy" aortic valve as a cause of aortic regurgitation. A clinico-morphologic study. Int J Cardiol 1985; 9:399-412. [PMID: 4077299 DOI: 10.1016/0167-5273(85)90234-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A clinico-pathologic study was performed in 25 patients undergoing aortic valve replacement because of regurgitation, caused by myxoid degeneration of the valve leaflets. Associated cardiac anomalies were floppy mitral valve (2 cases), floppy mitral valve and idiopathic hypertrophic subaortic stenosis (1), left atrial myxoma (1), and aortic coarctation at the isthmus (1). Three patients died (2 immediately and 1 on the 30th postoperative day). Pathological studies of the explanted valves showed deformities characterized by redundant thin leaflets which appeared soft and gelatinous. On histologic examination the fibrous layer of the leaflets was seen to be infiltrated by myxomatous tissue. Echocardiography showed the aortic root to be dilated in 13 patients and normal in the others. In those with normal aortic root, the histological examination of aortic wall disclosed minimal cystic medial necrosis in two cases. In contrast, more severe forms of cystic medial necrosis were evident in all patients having a dilated aortic root. Aortic valve replacement was performed in all cases. It was accompanied by a Bentall procedure (1 case), repair of ascending aorta dissection (2), replacement of the ascending aorta (1), mitral valve replacement (2), mitral valve replacement and apico-ascending aorta conduit (1) and excision of a left atrial myxoma (1). Our experience suggests that prolapse of the aortic valve due to floppy leaflets is a common degenerative disease which is generally associated with noninflammatory aortic root degeneration. This, together with aortic root dilatation, contributes to valve insufficiency. Nevertheless, the disease, when isolated (with normal aortic root), is liable in itself to produce aortic regurgitation. The need for early diagnosis is stressed, so as to be able to perform valve replacement.
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Shapiro LM, Thwaites B, Westgate C, Donaldson R. Prevalence and clinical significance of aortic valve prolapse. Heart 1985; 54:179-83. [PMID: 4015927 PMCID: PMC481875 DOI: 10.1136/hrt.54.2.179] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The prevalence and clinical significance of aortic valve prolapse were determined prospectively in 2000 consecutive patients undergoing routine clinical cross sectional echocardiography. Two hundred and twelve patients were excluded because the aortic cusps were not adequately visualised. Aortic valve prolapse was defined as downward displacement of cuspal material below a line joining the points of attachment of the aortic valve leaflets. Twenty four cases of aortic valve prolapse (1.2%) were identified. The patients were aged 12-64 years and nine were women. All had underlying valvar heart disease and the commonest lesion (in 11 cases) was prolapse of the larger cusp in bicuspid valves. Aortic valve prolapse was seen in four patients with mitral valve prolapse (two with severe regurgitation), one of whom had marfanoid aortic root dilatation. The remaining examples of aortic prolapse were seen in patients with various disorders including one with pulmonary atresia, two with aortic root disease (one with dissection and one with idiopathic dilatation), and one case of severe mitral regurgitation. Valves destroyed by infective endocarditis were seen in two cases. Aortic valve prolapse may be detected in various cardiac disorders and does not imply the presence of aortic regurgitation, but when bicuspid aortic valves are present it may well be important in producing such regurgitation. Although aortic valve prolapse may be associated with severe forms of mitral valve prolapse, these patients rarely have aortic regurgitation.
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Jaworsky C, Smith DW, Shindler D, Kostis J. Recurrent nontraumatic aortic tears resulting in valvular avulsion and aortic insufficiency. Clin Cardiol 1985; 8:173-5. [PMID: 3978889 DOI: 10.1002/clc.4960080310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
A case of aortic insufficiency due to avulsion of two of three semilunar valves was remarkable because of the intimal and medial tears which caused it. The tears were in different stages of repair, suggesting repetitive injury. Antemortem steroid therapy and bouts of violent coughing may explain these unusual findings.
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Abstract
Clinical and pathologic data were reviewed in 55 patients who had valve replacement for pure aortic regurgitation (AR) during a 6-year period. The clinical histories established the cause for AR in 34 cases: 11 rheumatic, 13 infective endocarditis, 4 congenital, 4 associated with aortic aneurysms and 2 the Marfan syndrome. In the valves from the other 21 patients, 13 had myxoid degeneration, defined as significant disruption of the valve fibrosa and its replacement by acid mucopolysaccharides and cystic change. Myxoid degeneration was also the primary pathologic abnormality in the 2 patients with the Marfan's syndrome, in 3 patients with a history of rheumatic disease and in 1 patient with a history of infective endocarditis. The patients with myxoid degeneration of uncertain origin were predominantly elderly (average age 63 years), had a long-standing history of systemic hypertension (77%) and had coronary artery disease (46%); 85% were male. In these patients the replacement valves were not larger than those of the other groups studied, indicating that dilatation of the aortic anulus was not a significant factor in the pathogenesis of the valve disease. These findings indicate that myxoid degeneration of the aortic valve is common (36% of all valves examined) and, in many cases, may be secondary to long-standing systemic hypertension.
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Stewart WJ, King ME, Gillam LD, Guyer DE, Weyman AE. Prevalence of aortic valve prolapse with bicuspid aortic valve and its relation to aortic regurgitation: a cross-sectional echocardiographic study. Am J Cardiol 1984; 54:1277-82. [PMID: 6507297 DOI: 10.1016/s0002-9149(84)80080-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Although aortic valve prolapse (AVP) has been suggested as a cause of aortic regurgitation (AR) in patients with bicuspid aortic valves, neither the frequency of AVP nor its relation to AR in this setting has been defined. To assess these relations, 64 patients with bicuspid aortic valves diagnosed by 2-dimensional echocardiography and 20 normal subjects, similarly distributed according to age and sex, were studied. The presence and degree of AVP were defined using 3 quantitative terms: aortic valve prolapse distance (AVPD), area (AVPA) and volume (AVPV). Each was corrected (c) for patient size with reference to the diameter of the aorta at the level of insertion of the valve cusps. In normal subjects, the AVPDc averaged 0.09 +/- 0.06 (range 0 to 0.16) and the AVPAc averaged 0.08 +/- 0.06 cm (range 0 to 0.15). In patients with bicuspid aortic valves, the AVPDc averaged 0.26 +/- 0.10 (range 0.11 to 0.59, p = 0.00005 vs normal subjects), whereas the AVPAc averaged 0.35 +/- 0.17 cm (range 0.05 to 0.90, p = 0.00005 vs normal subjects). When the AVPDc criteria were used, 81% of the bicuspid valves were abnormal; when the AVPAc criteria were used, 87% were abnormal. The degree of prolapse defined by the AVPVc, which considers both cusp area and degree of apical displacement, was significantly greater for patients with bicuspid aortic valve with clinical AR than for those without (p = 0.008). However, because of the overlap between groups, there was no point at which this measure uniquely separated patients with and without AR.(ABSTRACT TRUNCATED AT 250 WORDS)
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Abstract
The gross surgical pathologic features of the aortic valve were reviewed in 225 patients who had had clinically pure aortic insufficiency and aortic valve replacement at our institution during the years 1965, 1970, 1975, and 1980. The four most common causes of aortic regurgitation were postinflammatory disease (46%), aortic root dilatation (21%), incomplete closure of a congenitally bicuspid aortic valve (20%), and infective endocarditis (9%). Other causes of aortic incompetence in our study included ventricular septal defects (2%) and quadricuspid aortic valves (1%); the cause was indeterminate in 1%. The mean age of patients at valve replacement was approximately 50 years for all etiologic factors except a ventricular septal defect. All forms of aortic insufficiency were much more common in male than in female patients, except the postinflammatory and indeterminate types, which occurred approximately equally in both sexes. Moreover, the incidences of postinflammatory disease and aortic root dilatation changed appreciably with time. Before 1980, their incidences were 51% and 17%, respectively, but during 1980, they were 29% and 37%, respectively. Accordingly, aortic root dilatation is now the most common cause of pure aortic regurgitation in our surgical population. The decrease in the incidence of postinflammatory disease may be a result of the decreasing incidence of acute rheumatic fever reported in western countries.
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Abstract
A previously healthy 34-year-old Dutch immigrant to Australia died unexpectedly in his sleep. At autopsy the only significant finding was a floppy aortic valve (FAV). Histologic, histochemical and electron microscopic studies corroborated the macroscopic diagnosis. Previously described associations of the FAV include the floppy mitral valve, Marfan's syndrome, aortic root dilatation and aortic cystic medial necrosis. None of these features were found in the present case which is the first recorded example of isolated FAV presenting as sudden death. The mechanism of death is obscure, and while it is presumed to be dysrhythmic, a detailed histological examination of the cardiac conducting system revealed no anatomic abnormality.
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Morganroth J, Jones RH, Chen CC, Naito M. Two dimensional echocardiography in mitral, aortic and tricuspid valve prolapse. The clinical problem, cardiac nuclear imaging considerations and a proposed standard for diagnosis. Am J Cardiol 1980; 46:1164-77. [PMID: 7006361 DOI: 10.1016/0002-9149(80)90287-8] [Citation(s) in RCA: 114] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The mitral valve prolapse syndrome may present with a variety of clinical manifestations and has proved to be a common cause of nonspecific cardiac symptoms in clinical practice. Primary and secondary forms must be distinguished. Myxomatous degeneration appears to be the common denominator of the primary form. The diagnostic standard of this form has not previously been defined because the detection of mitral leaflet tissue in the left atrium (prolapse) on physical examination or angiography is nonspecific. M mode echocardiography has greatly enhanced the recognition of this syndrome but has not proved to be the best diagnostic standard because of its limited view of mitral valve motion. The advent of two dimensional echocardiography has provided the potential means for specific identification of the mitral leaflet motion in systole and can be considered the diagnostic standard for this syndrome. Primary myxomatous degeneration with leaflet prolapse is not localized to the mitral valve. Two dimensional echocardiography has detected in preliminary studies tricuspid valve prolapse in up to 50 percent and aortic valve prolapse in about 20 percent of patients with idiopathic mitral valve prolapse.
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Mardelli TJ, Morganroth J, Naito M, Chen CC. Cross-sectional echocardiographic detection of aortic valve prolapse. Am Heart J 1980; 100:295-301. [PMID: 7405799 DOI: 10.1016/0002-8703(80)90141-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Becker AE, Düren DR. Spontaneous rupture of bicuspid aortic valve. An unusual cause of aortic insufficiency. Chest 1977; 72:361-2. [PMID: 142617 DOI: 10.1378/chest.72.3.361] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This report documents the clinicopathologic correlation between pure aortic regurgitation and an exceptional form of congenitally bicuspid aortic valve. The patient was known for many years to have mild aortic insufficiency. His condition suddenly deteriorated, with signs of an aggravated aortic regurgitation. Infectious endocarditis was considered, but the diagnosis was never established. Surgery revealed an exceptional form of a bicuspid aortic valve in which the conjoined cusp had prolapsed, due to rupture of a fibrous strand which previously had anchored the free rim of the cusp to the inner wall of the aorta. There were no signs of infectious endocarditis. It is suggested that spontaneous rupture of the cord caused the sudden aggravation of aortic regurgitation.
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