Echocardiographic manifestation of right sinus of Valsalva aneurysm

Case report: Acute ST-elevation myocardial infarction and cardiogenic shock caused by a giant right sinus of Valsalva aneurysm and right coronary artery compression

A sinus of Valsalva aneurysm (SVA) is a rare aortic disease that may be congenital or acquired. Patients with an intact SVA are usually asymptomatic, whereas a ruptured SVA may cause acute chest pain and dyspnea. We present a rare case of acute ST-elevation myocardial infarction and cardiogenic shock in a 51-year-old man. Emergency coronary angiography revealed a giant aneurysm with an absence of flow in the right coronary artery. Both two-dimensional echocardiography and computed tomography angiography showed a giant right SVA, which ruptured into the pericardial sac and led to extrinsic compression of the right coronary artery. Surgical repair combined with coronary bypass grafting was performed. Unfortunately, the patient died from low cardiac output syndrome and postoperative multiple organ failure. This case highlights that the possibility of SVA rupture should be considered in acute myocardial infarction cases and that echocardiography and coronary computed tomography angiography are important in providing an accurate and rapid SVA diagnosis.

Left ventricular false tendons: echocardiographic, morphologic, and histopathologic studies and review of the literature

BACKGROUND

Left ventricular false tendons (LVFTs) are fibrous or fibromuscular bands stretching across the left ventricle (LV) from the ventricular septum to the papillary muscle or LV free wall but not connecting, like the chordae tendinae, to the mitral leaflet. LVFTs have become the focus of studies and discussions since the advent of echocardiography.

MATERIALS AND METHODS

We prospectively studied the prevalence of LVFTs by two-dimensional echocardiography in 476 infants and children referred to our institute for cardiac evaluation and cardiology workup. We also studied the morphology and histopathology of LVFTs in 68 congenital heart disease specimens and in 20 piglet hearts. The literature was reviewed and the clinical significance of LVFTs was discussed.

RESULTS

LVFTs of varying size and different location were detected in 371 (77.9%) of 476 infants and children studied, in 42 (61.8%) of 68 congenital heart disease specimens, and in 19 (95.0%) of 20 piglet hearts. Of the 75 LVFTs from the congenital heart disease specimens, 33 (44.4%) were fibrous type, measuring less than 1.4mm; 38 (50.7%) were fibromuscular type, 1.5-2.4mm; and 4 (5.3%) were muscular type, 2.5mm or more in diameter. Of the 33 LVFTs from the piglet hearts, 23 (69.7%) and 10 (30.3%) were fibrous and fibromuscular, respectively, and none (0.0%) was muscular.

CONCLUSIONS

LVFTs were detected partially or completely by modified two-dimensional echocardiography in both normal and abnormal hearts. LVFTs is a useful anatomical landmark of LV for the differentiation of morphological LV and right ventricle in segmental analysis of congenital heart disease. LVFTs are a cause of functional murmur. No pressure gradient was noted in the mid-LV or outflow tract. LVFTs could be a contributory factor in the generation of dysrhythmias during LV catheterization studies. LVFTs were more easily identifiable in neonates and young age patients because of a better delineation of images in echocardiography.

Aneurysms of the Sinuses of Valsalva

Sinus of Valsalva aneurysms are rare cardiac anomalies which may be acquired or congenital, most commonly involving the right or noncoronary sinuses. The congenital aneurysms are more common and often caused by weakness at the junction of the aortic media and the annulus fibrosus. Acquired aneurysms are caused by conditions affecting the aortic wall, such as infections (syphilis, bacterial endocarditis, or tuberculosis), trauma, or connective tissue disorders. Unruptured aneurysms are usually found incidentally during diagnostic studies. More commonly, sinus of Valsalvaaneurysms are diagnosed after clinical sequelae of rupture. Diagnosis of sinus of Valsalva aneurysm is facilitated by echocardiography, contrast aortography, and more recently, magnetic resonance imaging. Repair is generally required for ruptured aneurysms; unruptured aneurysms encroaching on nearby structures, causing myocardial ischemia, or having the potential to rupture warrant repair. A review of the literature is presented focusing on anatomy, clinical presentation of ruptured and unruptured aneurysms, noninvasive diagnostic modalities, and techniques for repair of this anomaly.

[Multiplane transesophageal echocardiography in the preoperative evaluation of the sinus of Valsalva fistula to right chambers]

INTRODUCTION AND OBJECTIVES

Ruptured sinus of Valsalva aneurysm to right cardiac chambers is an uncommon lesion in Western countries. The prognosis is usually serious unless the condition is promptly treated surgically. For this reason an accurate anatomical and functional evaluation is necessary. The main purpose of this report is to compare the usefulness of multiplane transesophageal echocardiography with transthoracic echocardiography and angiocardiography in the preoperative evaluation of ruptured sinus of Valsalva aneurysm to right chambers.

PATIENTS AND METHOD

Since January 1990, 9 patients (mean age 36,3 18 yr, 6 males) with ruptured sinus of Valsalva aneurysm to right chambers were studied. The pathogenesis was congenital aneurysm in 6 patients, aortic prosthesis endocarditis in one and two cases of iatrogenia: during a percutaneous mitral valvuloplasty and after cardiac surgery. Transthoracic echocardiography was performed in all cases, transesophageal echocardiography in 7 and angiocardiography in 8. Two patients died before surgery, and 7 were successfully operated on.

RESULTS

Transesophageal echocardiography was more useful when compared to transthoracic echocardiography and angiocardiography in detecting: a) the fistula; b) the sinus involved; c) the right chamber affected; d) congenital aneurysms morphology and size; e) aneurysm prolapse through a ventricular septal defect, y f) the identification of other cardiac congenital or acquired anomalies.

CONCLUSIONS

Multiplane TEE is the most accurate tool in the preoperative evaluation of ruptured sinus of Valsalva aneurysm to right chambers.

Unruptured congenital aneurysm of the sinus of Valsalva presenting with pulmonary stenosis

Congenital aneurysm of the sinus of Valsalva is a rare cardiovascular anomaly. It is usually silent until rupture occurs. The natural history of unruptured aneurysm of the sinus of Valsalva is still not clear, and the therapeutic strategy is uncertain. Here we reported a case of unruptured aneurysm of the sinus of Valsalva which was correctly diagnosed before invasive diagnostic procedures. A 30-year-old female noted mild palpitation and dyspnea for 1 month. Physically, a grade 3/6 systolic ejection murmur at upper left sternal border was detected. Echocardiography revealed dilatation and irregular protrusion of the right sinus of Valsalva encroaching on right ventricular outflow tract to cause obstruction. With these findings, unruptured aneurysm of the sinus of Valsalva with pulmonary stenosis was diagnosed. Cardiac catheterization and angiography confirmed the diagnosis. The aneurysm was repaired with a Dacron patch with good results. It is concluded that sinus of Valsalva aneurysm can be diagnosed by echocardiography before its rupture so as to render a proper management for this potentially life-threatening anomaly.

Aneurysms of sinus of Valsalva eroding into the interventricular septum: etiopathology and surgical considerations

OBJECTIVE

To evaluate and discuss etiopathology, clinical manifestations and surgical outcome of a rare subset of unruptured aneurysm of the sinus of Valsalva which erodes into the interventricular septum.

METHODS

Between 1989 and 1995, seven cases of unruptured aneurysm of the sinus of Valsalva eroding into the interventricular septum underwent surgical correction at the King Edward VII Memorial Hospital, Bombay. The origin of all these aneurysms was from the right coronary sinus. The mean age of presentation was 31 years. All patients were male. Calcification of the aneurysm was seen in three. Three patients presented without aortic regurgitation; all had complete heart block. Four patients presented with aortic regurgitation and in addition, two had complete heart block. Preoperative left ventricular function was poor in patients with aortic regurgitation (Ejection fraction range; 30-42%), when compared to those without aortic regurgitation (Ejection fraction range; 48-52%). Of those without aortic regurgitation at initial presentation, one patient developed progressive aortic regurgitation after 3 years requiring surgery. While two other patients were operated at earliest for closure of aneurysm, even in the absence of aortic regurgitation. All those with aortic regurgitation required surgery for aortic valve replacement and closure of aneurysm. Aneurysm was closed by direct suturing of the ostium in two patients and by patch closure in five patients. Permanent pacemaker was implanted in five patients.

RESULT

There was no operative death. Patients who underwent aortic valve replacement required postoperative ionotropic support. Two patients, who underwent surgery in absence of aortic regurgitation, remain free of aortic regurgitation at the end of 36 and 42 months of follow-up. One of the patients with calcific aneurysmal sac underwent successful re-replacement of the aortic valve for paravalvar leak after a 2 year interval.

CONCLUSION

Unruptured aneurysm of the sinus of Valsalva eroding into the interventricular septum should be operated at the earliest, which makes surgery simple and prevents development of complications such as aortic regurgitation and heart block.

The evaluation of the abdominal aorta: a "how-to" for cardiac sonographers

A thorough evaluation of the abdominal aorta can be readily achieved by use of the standard views of the echocardiographic examination. The ultrasound evaluation of the abdominal aorta represents a logical extension of the standard echocardiographic examination of the adult patient. This article provides the information needed to carry out a complete ultrasound examination of the abdominal aorta including the anatomy, the vascular disease, and the steps involved in accomplishing the ultrasound examination of the abdominal aorta.

Accurate localization of ruptured sinus of Valsalva aneurysm by real-time two-dimensional Doppler flow imaging

The surgical approach to the repair of a ruptured sinus of Valsalva aneurysm can depend on the cardiac chamber into which rupture occurs. This report details the color flow Doppler images in two patients who developed a right sinus of Valsalva aneurysm to right atrial fistula owing to bacterial endocarditis. In both cases, the color flow Doppler image was superior to contrast aortography in identifying the chamber into which rupture had occurred. The early experience with real-time two-dimensional Doppler flow imaging suggests that this noninvasive technique is valuable in the management of ruptured sinus of Valsalva aneurysms.

Two-dimensional echocardiographic identification of complicated aortic root endocarditis: implications for surgery

Two-dimensional echocardiography successfully displayed the location and extent of aortic root complications, annular abscess or mycotic aneurysm in nine patients with aortic valve endocarditis. Five of the nine patients had prosthetic valve endocarditis and four had native valve endocarditis. The infective process extended into the paravalvular structures, including the interventricular septum (seven patients), right ventricular outflow tract (three patients), interatrial septum (one patient) and anterior mitral valve leaflet (four patients). The amount of aorto-left ventricular discontinuity caused by these complications was quantitated in degrees of annular circumference on the parasternal short axis image and in distance on the parasternal long axis image. The echocardiographic findings were confirmed at surgery and were helpful in the preoperative anticipation of the type of surgical procedure required: aortic valve replacement or composite aortic valve and root replacement. Five patients had prosthetic valve endocarditis with calculated aorto-left ventricular discontinuity of 173 +/- 55 degrees on parasternal short axis images and 1.36 +/- 0.72 cm on parasternal long axis images. Initial surgical repair included three composite aortic root-valve prosthesis implants, one reconstructive procedure with valve replacement and one simple aortic valve replacement. During a follow-up period of 18 months (range 1 to 35), a second reparative procedure was required for only one patient to repair an aortic conduit to coronary artery venous bypass graft. Four patients had native valve endocarditis with calculated aorto-left ventricular discontinuity of 100 +/- 17 degrees on parasternal short axis images and 0.88 +/- 63 cm on parasternal long axis images. Initial surgical repair included two reconstructive procedures with valve replacement and two simple aortic valve replacements. During a follow-up period of 30 months (range 16 to 42), three of these four patients required a second reparative procedure: one each for repair of a paraprosthetic leak, a ventricular septal defect and persistent aorto-left ventricular discontinuity. Two-dimensional echocardiography accurately detected aortic annular abscess and mycotic aneurysm complicating aortic valve endocarditis and the resultant degree of aorto-left ventricular discontinuity. Circumferential aorto-left ventricular discontinuity with these complications is greater for prosthetic than native valve endocarditis and predicts a more extensive surgical repair.(ABSTRACT TRUNCATED AT 400 WORDS)

Left ventricular to left atrial communication secondary to a paraaortic abscess: color flow Doppler documentation

Aortic root abscess occurs frequently in aortic prosthetic valve infective endocarditis. The present echocardiographic report documents a ruptured abscess that led to a direct communication between the left ventricular outflow tract and the left atrium confirmed by real-time (color flow) Doppler imaging.

Cross-sectional echocardiographic diagnosis of unruptured right sinus of Valsalva aneurysm dissecting into the interventricular septum

We present a case of an unruptured right coronary sinus of Valsalva aneurysm with dissection into the interventricular septum diagnosed pre-operatively by cross-sectional echocardiography. The unique echocardiographic features of this rare, although potentially fatal congenital lesion, are described.

An unusual echocardiographic finding in a ruptured sinus of Valsalva aneurysm

A patient with a ruptured sinus of Valsalva aneurysm (RSVA) demonstrated an unusual two-dimensional echocardiographic manifestation of this entity. A discrete mass of echoes, appearing attached to a posterior leaflet of the tricuspid valve, moved to and fro into the right ventricle during diastole and into the right atrium in systole. This echocardiographic appearance mimics a vegetation of the tricuspid valve, a flail tricuspid leaflet, a right atrial myxoma or a pedunculated right atrial thrombus. Therefore, the differential diagnosis of this echocardiographic finding should include RSVA in addition to the above mentioned disorders.

Aneurysms of sinus of Valsalva: two-dimensional echocardiographic diagnosis and recognition of rupture into the right heart cavities

The aim of this study was to evaluate the role of echocardiography in the diagnosis of sinus of Valsalva aneurysms projecting toward the right heart cavities. Three patients who had a ruptured aneurysm of a sinus of Valsalva diagnosed by echocardiography and confirmed by catheterization underwent cardiac surgery. In two patients, the aneurysm originated from the right coronary sinus and had perforated into either the inflow or outflow tract of the right ventricle. In the third patient, the aneurysm, which originated from the noncoronary sinus, ruptured into the atrium. A fourth patient was also investigated and had an unruptured aneurysm of the right coronary sinus projecting into the right ventricular outflow tract. M-mode, two-dimensional and contrast echocardiographic studies were performed before cardiac catheterization in all patients and after surgery in three patients. M-mode echocardiography was useful only when the aneurysm had an anterior projection, whether or not the aneurysm was ruptured. Conversely, two-dimensional echocardiography was always able to identify the aneurysmal sac which appeared as an abnormal circular thin-walled structure protruding into the right heart cavities. By using multiple views, it was possible to investigate the whole abnormal structure and locate the sinus from which the aneurysm originated. The use of the echo contrast technique allowed more precise definition of the aneurysmal sac and diagnosis of a left to right shunt by demonstrating a negative contrast image in the right cavities. On the other hand, no negative contrast image was recorded in the patient with an unruptured aneurysm or in the two instances of a successful surgically reconstructed aorta.

Ruptured sinus of valsalva aneurysm in children: report of two cases and literature review

Two children with ruptured sinus of Valsalva aneurysm are described, each with a ventricular septal defect, and in one there was also an associated discrete subvalvular aortic stenosis. The diagnostic appearance of two-dimensional echocardiography and axial angiocardiography are emphasized to allow early diagnosis and surgical repair. A literature review of recent reports in English disclosed that 13 patients under age 20 had been reported to have ruptured sinus of Valsalva aneurysm.

Aorto-left ventricular communication after closure. Late postoperative problems

The long-term follow-up of six patients operated on for aorto-left ventricular communication has been reviewed in detail. All had residual aortic regurgitation after the initial repair of the defect. It was severe in four and required repeated reoperation in three with ultimate aortic valve replacement. The failure of early repair to solve the haemodynamic problem has provoked a reconsideration of the basic anatomy, of the surgical approach, and of the postoperative physiology of this anomaly. The so called "tunnel" is not a tunnel with length but should be considered as a localised breach at the insertion of the right coronary cusp. The localised aortic root dilatation at the site is a weakness that remains after closure of the tunnel leaving a poorly supported aortic valve and a weak root. Thus, the initial repair of the aorto-left ventricular communication must not only close the communication but reinforce, strengthen, and support the right aortic sinus in order to maintain cusp competence.

Anomalous chordae tendinae. A source of echocardiographic confusion

A unique instance of an anomalous chorda tendinae visualized in the left ventricular outflow tract during M-Mode and two-dimensional echocardiography, and subsequently confirmed during surgery for concomitant severe rheumatic valvular disease, is described. The M-Mode appearance can be confused with more serious forms of heart disease manifesting extraneous echoes in the outflow tract, and an approach to these echoes is described, based on a review of the literature.

Echocardiographic detection of subvalvar aortic root aneurysm extending to mitral valve annulus as complication of aortic valve endocarditis

Acute aortic regurgitation as a consequence of infective endocarditis developed in a young man after peritonitis. A large subvalvar aortic root aneurysm extending to the mitral valve annulus together with features of severe acute aortic regurgitation were shown by M-mode echocardiography. The echocardiographic findings were confirmed at operation when obliteration of the aneurysmal space and aortic valve replacement were performed. Postoperative echocardiography confirmed obliteration of the aneurysmal space.

Ruptured aneurysm of the right sinus of Valsalva: two pulsed Doppler echocardiographic studies

Pulsed Doppler echocardiography (PDE) was performed on two cases with ruptured aneurysm of the right sinus of Valsalva into the right ventricle. PDE revealed a wide band pattern throughout the cardiac cycle when the sample volume was placed within the aneurysm. In the right ventricle below the aneurysm, a continuous disturbed flow in case 1 and a diastolic turbulence in case 2, was widely recorded, respectively. In contrast, the flow pattern of the right ventricular outflow tract distal to the aneurysm showed a systolic disturbed flow in both cases. These PDE findings were consistent with the shunt flows in angiocardiography.

Echocardiographic features of the false tendons in the left ventricle

M mode and two dimensional echocardiographic features consistent with previously reported autopsy findings of false tendons were seen in 5 of approximately 1,000 consecutive echocardiographic examinations. Later, the presence of false tendon was proved at autopsy in one of the five cases. Examination in three cases revealed heart disease: aortic regurgitation, third degree atrioventricular (A-V) block with aortic regurgitation and invasive thymoma with pericardial effusion; examination in two cases revealed no heart disease. In three cases, M mode echocardiograms revealed in the outflow tract of the left ventricle abnormal linear echoes that strongly mimicked those in other disorders such as discrete subaortic stenosis or flail aortic valve. In two cases, there were abnormal linear echoes in the left ventricle toward the apex. In three cases, two dimensional echocardiograms revealed long-string-like echoes stretching from the upper part of the interventricular septum across the ventricular cavity to the lateral wall of the left ventricle in long and short axis views or in four chamber views. In two cases, long slender echoes between the lower parts of the interventricular septum and the left ventricle were seen in apical long axis views. These string-like echoes seem to represent the false tendons previously reported at autopsy, although actual pathologic confirmation was available in only one of the five cases. It is concluded that (1) M mode and two dimensional echocardiograms can demonstrate the presence of false tendons, (2) two dimensional echocardiograms are useful in differentiating false tendons from other conditions causing abnormal linear echoes in the outflow tract of the left ventricle on M mode echography.

Detection of ruptured aneurysm of sinus of Valsalva by contrast two-dimensional echocardiography

The M-mode and two dimensional echocardiographic features are described of a patient with rupture of a sinus of Valsalva aneurysm into the right atrium. A clear echo-free zone arising from the tip of the aneurysm is visualised in the right atrium in diastole by peripheral injection of echocardiographic contrast material. At surgery a fistula was seen between the non-coronary cusp and the right atrium.

Giant Lambl's excrescences of papillary muscle and aortic valve: echocardiographic, angiographic, and pathologic findings

A 54-year-old female with rheumatic heart disease was found to have a mass in the left ventricle by echocardiography and angiography. Subsequently, giant Lambl's excrescences of papillary muscle and aortic valve were confirmed by operation and pathologic examination. Possible complication from cardiac catheterization could be avoided by the utilization of echocardiography prior to catheterization.

Uncomplicated sinus of Valsalva aneurysm detected by echocardiography in an asymptomatic patient: case report

Echocardiography was extremely useful in detecting a distinctive echographic pattern with uncomplicated right sinus of Valsalva aneurysm. The patient was clinically asymptomatic. The chest x-ray showed a normal cardiac silhouette. Electrocardiographic abnormalities including first degree atrio-ventricular block, right bundle branch block, and left anterior hemiblock observed during a routine cardiac clinic visit led to the echocardiographic investigation. The right sinus of Valsalva aneurysm protruded high into the septum and into the left ventricular chamber adjacent to the interventricular septum. At surgery, the aneurysm was closed by the placement of a Dacron elastic patch.

Fungal endocarditis complicated by mycotic aneurysm of sinus of Valsalva, interventricular septal abscess, and infectious pericarditis: unique M-mode and two-dimensional echocardiographic findings

A 26-year-old male with fungal aortic endocarditis is presented in whom unique M-mode and two-dimensional echocardiographic findings permitted a diagnosis of mycotic aneurysm of right sinus of Valsalva and ventricular septal abscess preoperatively. The aneurysm was excised, and the affected aortic and tricuspid valves were replaced with valve prostheses.

Ruptured sinus of Valsalva aneurysm: diagnosis by echocardiography

Fluttering of the right side of the interventricular septum noted on M-mode echocardiography in association with a bulging of the right sinus of Valsalva detected by two-dimensional echocardiography were present in a patient. These two echocardiographic findings should alert the clinician to a diagnosis of a ruptured sinus of Valsalva aneurysm.

Echocardiographic features of an unruptured aneurysm of the right sinus of Valsalva

A 2-cm aneurysm of the right sinus of Valsalva was documented in a patient with a prosthetic aortic valve. The M-mode findings differed from prior reports and mimicked those of aortic root dissection or a catheter placed in the right ventricular outflow tract. Two-dimensional echocardiograms readily distinguished the aneurysm of the right sinus of Valsalva from the alternative possibilities.

Aneurysm of the left sinus of Valsalva draining into the right atrium

We report the case of an arteriovenous fistula connecting the aorta to the right atrium, due to a ruptured aneurysm of the left sinus of Valsalva. Clinical, echocardiographic, and angiographic aspects of this unusual lesion are discussed and correlated. Emphasis is put on the diagnostic value of the echocardiogram; a characteristic dense echo parallel to the posterior aortic wall is seen, along with signs of right ventricular volume overload. Combined with the case history and auscultatory finding (a continuous murmur on the right sternal edge), this may lead to the correct diagnosis by noninvasive means.

Echocardiographic features of an aneurysm of the left sinus of Valsalva

The echocardiographic features of an aneurysm of the left sinus of Valsalva are described and correlated with angiographic findings. The echocardiogram showed the presence of a thin line of echoes occurring proximal to the anterior leaflet of the mitral valve and moving in and out of apposition with the posterior aortic wall. During systole, this line of echoes moved away from the aorta into the left atrium, and during diastole, the line moved into the aorta. Recognition of these features provides a potential noninvasive way to diagnose aneurysms of the left sinus of Valsalva prior to rupture.

Left ventricular myxoma: echocardiographic diagnosis and review of the literature

A 33 year old man with the findings of mild aortic stenosis had an echocardiographic diagnosis of left ventricular myxoma prolapsing through the aortic valve during each ventricular systole. The M-mode echocardiogram, B-scan ultrasonogram and angiograms of this patient are presented. The clinical characteristics in all the reported cases of left ventricular myxomas are reviewed.

Echocardiographic manifestations of ruptured aortic valvular leaflets in the absence of valvular vegetations

The diagnosis of ruptured (perforated or torn) aortic valvular leaflets due to various causes has been made primarily at surgery or postmortem examination. Although angiocardiographic studies readily reveal aortic regurgitation, they rarely establish the presence of a ruptured aortic cusp as the cause of the aortic leak. Recent echocardiographic experience has brought to our attention seven patients with ruptured aortic valvular leaflets in whom the absenc of valvular vegetations was confirmed at surgery in six and at autopsy in one. The echocardiogram of the aortic root in these subjects revealed little or no increment in the diameter of the aortic root. In systole the usual box-like configuration of the leaflets, similar to that observed in normal subjects, was seen; however, in diastole the normal thin midaortic linear echoes were replaced by a thick band of echoes which often revealed high-frequency oscillations. In addition, high-frequency fibrations of the anterior mitral leaflet in diastole and increased systolic excursion of the interventricular septum and left ventricular posterior wall were observed.

Aortic regurgitation associated with ventricular septal defect. Echocardiographic and hemodynamic observations

Ventricular septal defect is sometimes associated with aortic regurgitation. In this report, an echocardiogram demonstrating dramatic prolapse of the noncoronary cusp into the left ventricular outflow tract and ventricular septal defect in a patient with Down's syndrome and ventricular septal defect, confirmed by angiographic studies, is presented. The echocardiogram supports the concept of anatomic lack of support of the aortic ring due to a deficient septum and hemodynamically significant flow of blood to the right ventricle through the ventricular septal defect, resulting in trauma to aortic cusps and prolapse.

Significance of abnormal echoes in left ventricular outflow tract

We have observed abnormal echoes in the left ventricular outflow tract in 4 patients: 3 of the subjects had bacterial endocarditis and the fourth patient had myxomatous degeneration of the aortic valve (floppy aortic valve). A single diastolic echo with fine high frequency fluttering was seen in the patient with the floppy aortic valve, whereas the patients with endocarditis had associated infection of the mitral valve and an aneurysm of the anterior mitral leaflet, which was represented by dense systolic echoes on the proximal part of the mitral valve...