Echocardiography of the "floppy" aortic valve. Report of a case

Reliability and identification of aortic valve prolapse in the horse

BACKGROUND

The objectives were to determine and assess the reliability of criteria for identification of aortic valve prolapse (AVP) using echocardiography in the horse.

RESULTS

Opinion of equine cardiologists indicated that a long-axis view of the aortic valve (AoV) was most commonly used for identification of AVP (46%; n=13). There was consensus that AVP could be mimicked by ultrasound probe malignment. This was confirmed in 7 healthy horses, where the appearance of AVP could be induced by malalignment. In a study of a further 8 healthy horses (5 with AVP) examined daily for 5 days, by two echocardiographers standardized imaging guidelines gave good to excellent agreement for the assessment of AVP (kappa>0.80) and good agreement between days and observers (kappa >0.6). The technique allowed for assessment of the degree of prolapse and measurement of the prolapse distance that provided excellent agreement between echocardiographers, days and observers (kappa/ICC>0.8). Assessments made using real-time zoomed images provided similar measurements to the standard views (ICC=0.9), with agreement for the identification of AVP (kappa>0.8). Short axis views of the AoV were used for identification of AVP by fewer respondents (23%), however provided less agreement for the identification of AVP (kappa>0.6) and only adequate agreement with observations made in long axis (kappa>0.5), with AVP being identified more often in short axis (92%) compared to long axis (76%). Orthogonal views were used by 31% of respondents to identify the presence of AVP, and 85% to identify cusp. Its identification on both views on 4 days was used to categorise horses as having AVP, providing a positive predictive value of 79% and negative predictive value of 18%. Only the non-coronary cusp (NCC) of the AoV was observed to prolapse in these studies. Prolapse of the NCC was confirmed during the optimisation study using four-dimensional echocardiography, which concurred with the findings of two-dimensional echocardiography.

CONCLUSIONS

This study has demonstrated reliable diagnostic criteria for the identification and assessment of AVP that can be used for longitudinal research studies to better define the prevalence and natural history of this condition.

Non-inflammatory aortic root disease and floppy aortic valve as cause of isolated regurgitation: a clinico-morphologic study

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)

Aortic valve prolapse with aortic regurgitation assessed by Doppler color-flow echocardiography

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.

Prolapse of the "floppy" aortic valve as a cause of aortic regurgitation. A clinico-morphologic study

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.

Echocardiographic study of cardiac abnormalities in families of patients with Marfan's syndrome

Twelve patients (5 male and 7 female; mean age 17.7 +/- 12.3 years, range 5 to 42) with Marfan's syndrome and 48 of their first degree relatives (16 male and 22 female; mean age 29.8 +/- 17.3 years, range 4 to 60) were evaluated for cardiac abnormalities by echocardiography. Of the patients with Marfan's syndrome, aortic valve prolapse was present in 1, tricuspid valve prolapse in 4, mitral valve prolapse in 12 and aortic root dilation in 10. Of the 48 first degree relatives of these 12 patients, tricuspid valve prolapse was diagnosed in 3, mitral valve prolapse in 15 and aortic root dilation in 12; aortic valve prolapse was not observed in any of these subjects. Of the 60 persons studied in these 12 kindreds, 28 (47%) had cardiac involvement. Among the 28 with cardiac involvement, aortic valve prolapse was observed in 1 (3.5%), tricuspid valve prolapse in 7 (25%), mitral valve prolapse in 27 (96%) and aortic root dilation in 22 (79%). Mitral valve prolapse was also present in the seven subjects with tricuspid valve prolapse and one with aortic valve prolapse. In 32 of the 60 persons studied in the 12 families, at least one abnormality of the cardiac, skeletal or ophthalmologic system was observed. Nineteen subjects were younger than 18 years of age; all had cardiac involvement associated with Marfan's syndrome. The notably earlier presentation of cardiac involvement in young persons may be responsible for a shorter life span in this group.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic features in spontaneous disruption of implanted tissue aortic valves

The echocardiographic features were recorded in three patients with spontaneous disruption of implanted tissue aortic valves. Two of the patients had xenografts, and one had a homograft. Aortic regurgitation had developed in all three spontaneously in the absence of active infective endocarditis. In each case there was severe disruption of the valve. Similar echocardiographic features have been found, usually in association with infective endocarditis or with myxomatous degeneration of the aortic valve. They have not previously been reported in association with implanted tissue aortic valves.

Echographic early systolic partial closure (notching) of the aortic valve in congestive cardiomyopathy

We investigated the prevalence and significance of aortic valve early systolic partial closure (notching) in congestive cardiomyopathy by reviewing clinical and M-mode echocardiographic findings in 33 patients. We also compared their echocardiographic aortic root and valve findings to those in 17 aortic regurgitation patients and 24 normal subjects. Thirteen cardiomyopathy patients (39%) exhibited aortic valve partial closure--similar to the prevalence in the aortic regurgitation (41%) and normal (33%) groups. However, patients with dilated cardiomyopathy and aortic valve notching exhibited a higher mean percentage of partial closure (18% +/- 10) than those with notching in either the aortic regurgitation (8% +/- 9) or normal (5% +/- 2) group. There was no significant difference in age, body surface area, left ventricular dimension, systolic function, or presence of mitral regurgitation between cardiomyopathy patients with and without aortic valve notching, but the former had slightly greater aortic root dimensions and maximal aortic leaflet separation. Although the reason for this difference is unknown, a wider aortic root may result in low-pressure areas bordering the aortic flow stream during early systole, which may favor partial aortic valve closure.

Origin and clinical relevance of musical murmurs

Although our observations are limited to studies performed on a degenerated bioprosthetic valve that produced a musical murmur, we believe that they can be applied to musical murmurs caused by abnormal natural valves. Several points regarding the characteristics of musical murmurs have been clarified. A musical murmur results from a uniform periodic vibration of a cardiac structure. A non-musical murmur results from turbulent blood flow which initiates random vibrations of adjacent structures. The broad spectrum of frequency of a non-musical murmur reflects the broad range of random fluctuations of blood velocity that characterizes turbulent blood flow. The frequency, amplitude, and time of occurrence during systole or diastole of a musical murmur are dependent upon the hemodynamics in the vicinity of the vibrating structure. Variability of all of these characteristics of the murmur, therefore, may be expected. Musical murmurs may have a purer tone at a site distal to the source than close to the source. This may reflect a superimposition of a broad spectrum of noise due to turbulence close to the valve. With distance from the valve, turbulence attenuates more than the sound-pressure fluctuations which are due to the uniform vibrations of the valve. A pure tone, uncontaminated by this broad spectrum of noise due to turbulence, therefore, is heard at some distance from the valve.

Echocardiographic evaluation of porcine bioprosthetic valves: experience with 309 normal and 59 dysfunctioning valves

To determine the clinical value of echocardiographic evaluation of porcine bioprosthetic valves, the findings in all patients who had porcine bioprosthetic valve replacement and adequate quality echocardiographic studies from 1978 to 1982 were analyzed. The study includes 309 normal and 59 dysfunctioning valves. Valve dysfunction resulted from spontaneous cusp degeneration in 39 (34 valve regurgitations, 5 stenoses), infective endocarditis in 12, paravalvular regurgitation in 5, regurgitation of redundant cusps, mitral valve thrombi, and aortic stent stenosis in 3 others. Echocardiographic findings were correlated with gross surgical pathologic or autopsy findings in 45 of the 59 dysfunctioning valves. Echocardiographic abnormalities were demonstrated in 41 of 59 (69%) dysfunctioning valves. A systolic mitral or diastolic aortic valve flutter was diagnostic of a regurgitant valve caused by a torn or unsupported cusp margin and was observed in 28 of 34 (82%) regurgitant valves with no false-positive studies. Echocardiographic cusp thickness of greater than or equal to 3 mm correctly identified all regurgitant and stenotic valves with gross anatomic evidence of localized or generalized cusp thickening or calcific deposits. Echocardiographic valve abnormalities were observed in only 4 of 12 patients with infective endocarditis and in 1 of 5 with paravalvular regurgitation. Thus, echocardiography provides important information regarding the function of porcine bioprosthetic valves and is of value in the decision to replace these valves, especially when dysfunction is due to spontaneous cuspal degeneration. Echocardiography is neither sensitive nor specific in patients with infective endocarditis and paravalvular regurgitation.

A regurgitant jet and echocardiographic abnormalities in aortic regurgitation: an experimental study

Acute aortic regurgitation was created experimentally in 21 mongrel dogs to examine the relationship of the regurgitant jet to observed echocardiographic findings. The direction of the regurgitant jet was studied by echo contrast injections in the aortic root. Diastolic fluttering of the anterior mitral leaflet (AML) was noted in all 21 dogs irrespective of direction of the jet. Diastolic fluttering of the interventricular septum (IVS) was noted in six of the seven dogs with a tear of the noncoronary cusp and in one of seven dogs with lesions in the left coronary cusp. In all seven dogs with echocardiographically demonstrated IVS fluttering, a regurgitant jet impinged on the anterior part of the IVS. Amplitude of the AML excursion was not significantly different from control when the lesions involved the noncoronary or the left coronary cusps. However, all seven dogs that had a lesion in the right coronary cusp demonstrated a significant reduction in the amplitude of the AML excursion. The regurgitant jet in these dogs impinged uniformly on the AML. We conclude that diastolic fluttering of the AML is uniformly observed and unrelated to the direction of the regurgitant jet, diastolic fluttering of the IVS is caused by the regurgitant jet impinging upon the IVS, and amplitude of the AML may be reduced as a result of a jet impingement of the AML.

Mechanism of a musical systolic murmur caused by a degenerated porcine bioprosthetic valve

The cause of a musical (cooing) murmur produced by a degenerated bioprosthetic valve in the mitral position was investigated. Spectral analysis of the murmur recorded at the chest wall at the site of the maximum palpable impulse showed virtually all sound in a narrow frequency band around the dominant frequency of 158 hertz. The same valve, surgically removed and mounted in the mitral position in a pulse duplicating system, produced an audible musical murmur detected by a phonocatheter in the atrial chamber. Nearly all of the sound-pressure occurred in a narrow band of frequency around 145 hertz. High speed motion pictures (500 frames/s) showed systolic flutter of a flail leaflet. The frequency of this leaflet flutter was 142 hertz. Hot film anemometry showed minimal turbulence, all located near the margin of the regurgitant leaflet. The intensity of the murmur was unrelated to the intensity of turbulence. A second degenerated bioprosthetic valve that produced in vivo a typical blowing holosystolic mitral regurgitant murmur produced in vitro a murmur with a broad range of frequencies (20 to 500 hertz). With this valve, the intensity of the murmur was related to the intensity of the turbulence. Motion pictures showed no leaflet flutter. Flutter of an insufficient valve leaflet causing uniform and periodic high frequency fluctuating pressures therefore appeared to be the cause of the musical quality of the systolic murmur in a degenerated bioprosthetic valve.

Abnormal aortic valve echoes in mitral prolapse. Echocardiographic features of floppy aortic valve

The following distinctive combination of M-mode and two dimensional echocardiographic abnormalities of the aortic valve was observed in a group of 12 patients, of whom 11 had mitral valve prolapse. On two dimensional scans, the aortic cusps were freely mobile but appeared thickened or folded. On M-mode records, cusp excursion was normal: there was well defined systolic oscillation, and cusp echoes were multiple and centrally positioned within the aortic root during diastole. The aortic valve was inspected at operation in two patients: a typically myxomatous valve was replaced in one and findings were in keeping with this diagnosis in the other. It is suggested that the echocardiographic features described are characteristic of the floppy aortic valve. Despite the echocardiographic abnormalities, only three patients had clinical evidence of an aortic valve lesion. It is, therefore, further suggested that the investigation of patients with mitral prolapse should include echocardiographic assessment of the aortic valve, even when associated myxomatous degeneration of that valve is not suspected clinically.

Evaluation of combined valvular prolapse syndrome by two-dimensional echocardiography

The patterns of aortic and tricuspid valve motion in 50 patients with mitral valve prolapse were analyzed by wide-angle, phased-array, two-dimensional echocardiography. Twelve patients (24%) had redundant aortic leaflets bulging into the left ventricular outflow tract during diastole. Eight of 12 patients had aortic regurgitation and seven of 12 had M-mode echocardiographic evidence of aortic valve prolapse. One patient underwent mitral and aortic valve replacement, and the excised valves revealed marked myxomatous degeneration. Eight of 15 patients undergoing contrast echocardiography had tricuspid regurgitation (systolic reflux of contrast material into the inferior vena cava persisting for more than 10 beats), and prolapse in the septal leaflet of the anterior leaflet or both. A similar tricuspid valve pattern was noted in three of seven patients without tricuspid regurgitation. Tricuspid valve prolapse was identified in 20 patients (40%). Nine patients (18%) had combined prolapse of the mitral, aortic and tricuspid valves. In five patients with middiastolic high-pitched murmurs recorded along the left sternal border, tricuspid valve prolapse was demonstrated. In one of these patients, the presence of pulmonary regurgitation was confirmed by intracardiac phonocardiography. We conclude that two-dimensional echocardiography is useful for evaluating patients with combined valvular prolapse syndrome.

Two dimensional echocardiography in mitral, aortic and tricuspid valve prolapse. The clinical problem, cardiac nuclear imaging considerations and a proposed standard for diagnosis

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.

Flail aortic valve leaflets: M-mode and two-dimensional echocardiographic manifestations

Four patients with documented flail aortic valve leaflets were studied using M-mode and two-dimensional echocardiography (2-D echo). Two had aortic valve endocarditis, one had endocarditis involving a congenital heart defect, and one had a myxomatous aortic valve. Mitral valve flutter and early mitral valve closure led to the diagnosis of severe aortic insufficiency in three patients. Diastolic aortic valve flutter, considered to be specific for a flail aortic leaflet, was present in three patients. In the fourth patient left ventricular outflow tract (LVOT) echoes were present, but did not distinguish between a flail aortic leaflet and an aortic vegetation. Two-D echo confirmed LVOT echoes in all patients. Discrimination between a flail leaflet and a vegetation(s) without leaflet disruption was accomplished by noting the hinge point of the LVOT diastolic echoes, which was the aortic wall in patients with a flail leaflet. The combination of these M-mode and 2-D echocardiographic findings permitted the diagnosis of a flail aortic leaflet to be made accurately and noninvasively. In two patients surgery was performed without prior cardiac catheterization.

Echocardiographic findings in patients with aortitis syndrome

Echocardiography was performed in 18 patients with the aortitis syndrome and in 20 age-matched normal volunteers. The aortic root dimension, the aortic dimension at the level of the sinotubular ridge, the aortic arch dimension, the left ventricular internal dimension, the left atrial dimension, the interventricular septal thickness, and the left ventricular posterior wall thickness were measured. All measurements, except for the left atrial dimension, were significantly greater in patients with aortitis syndrome than in the control subjects. We concluded (1) that the patients with the aortitis syndrome may have an enlarged or narrowed aorta, a dilated left ventricle and left atrium, and a thickened interventricular septum and left ventricular posterior wall; (2) that the incidence and the degree of these abnormalities depend on the presence of complications such as aortic regurgitation and arterial hypertension; and (3) that M-mode as well a cross-sectional echocardiography plays an important role in the assessment of the aorta and heart in the aortitis syndrome.

Diastolic flutter of aortic valves in aortic regurgitation: a report of seven cases

Seven patients with aortic regurgitation, manifesting diastolic flutter of the aortic valve cusps (DFAVC) in the echograms, are described. Five patients with infective endocarditis revealed coarse or fine, irregular DFAVC. Two patients with severe aortic regurgitation and a musical murmur manifested regular DFAVC with a frequency identical to that of a simultaneously recorded diastolic murmur. Of the 5 patients with infective endocarditis, 4 required urgent aortic valve replacement and 1 died. The 2 patients with musical murmurs are clinically stable without surgery. This report extends the clinical spectrum of patients with DFAVC and describes the character of the flutter in patients with muscial murmurs. Furthermore, it suggests that DFAVC is a sign of severe aortic regurgitation.

Echocardiographic findings in prolapsed aortic cusp with vegetation

A patient with severe aortic regurgitation showed abnormal echoes in the left ventricular outflow tract compatible with aortic vegetation or flail aortic cusp. At operation, a pedunculated vegetation on a prolapsed aortic cusp was found. The case illustrates some of the pitfalls in the echocardiographic distinction of the two conditions.

Musical murmurs: an echo-phonocardiographic study

Five patients with muscial murmurs were studied noninvasively with simultaneous echocardiography and phonocardiograpy and phonocardiography. Three patients had aortic regurgitation, one mitral regurgitation and one tricuspid regurgitation. The frequency of the muscial murmurs ranged from 40 to 158 cycles/sec. The patient with tricuspid regurgitation manifested an inspiratory honk. Simultaneous echo-phonocardiography revealed regular valve leaflet flutter (aortic, mitral or tricuspid) at a frequency identical to that of the simultaneously recorded muscial murmur. This study demonstrates that echocardiography is a useful noninvasive tool in identifying the site of origin of musical murmurs.

Echocardiography of the aortic root

The anterior and posterior walls of the aortic root are recognized as a pair of parallel linear signals which move anteriorly in systole and posteriorly in diastole. Valve cusps appear as thin lines which move briskly toward the periphery of the aortic lumen in systole and coapt in the middle in diastole producing a box-like configuration. Cusp calcification results in the appearance of multiple, linear echoes within the aortic root. Mild aortic stenosis is characterized by lightly calcified leaflets whereas heavy calcification, which completely obscures cusp motion, signifies severe stenosis. Aortic aneurysms produce significant enlargement of the aortic root image; marked widening of the aortic walls indicates the presence of aortic root dissection, but there are important limitations and pitfalls in the diagnosis of this condition. A markedly eccentric diastolic cusp position within the aortic lumen resulting in asymmetric images of the leaflets in systole is the hallmark of a bicuspid aortic valve. An abrupt premature closure of the valve leaflets in early systole is typical of subaortic membranous stenosis. In tetralogy of Fallot the aortic root is dilated and overrides the ventricular septum.

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...

Echocardiographic manifestation of annuloaortic ectasia: its "paradoxical" motion of the aorta and premature systolic closure of the aortic vale

The echocardiographic features of annuloaortic ectasia were studied in 12 patients. Eleven of them exhibited skeletal and/or ophthalmic findings of Marfan's syndrome and one was considered as having forme fruste. Echocardiograms revealed not only marked dilatation of the aortic root but also unique motion of the aortic wall and aortic valve. Posterior motion of the posterior aortic wall during early to middle ejection period, i.e., "paradoxical" motion, was noted in eight cases, and premature systolic partial closure of the aortic valve was seen in all cases.