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Aortic regurgitation due to back-and-forth intimal flap movement detected by both multidetector computed tomography and transesophageal echocardiography
Journal of Cardiology Cases 7 (2013) e161–e163
Contents lists available at www.sciencedirect.com
Journal of Cardiology Cases journal homepage: www.elsevier.com/locate/jccase
Case Report
Aortic regurgitation due to back-and-forth intimal flap movement detected by both multidetector computed tomography and transesophageal echocardiography Hironori Hara (MD), Kengo Tanabe (MD, PhD) ∗ , Shuzou Tanimoto (MD, PhD), Jiro Aoki (MD, PhD), Sen Yachi (MD), Satoru Kishi (MD), Hiroyoshi Nakajima (MD, PhD, FJCC), Takeshi Miyairi (MD, PhD), Kazuhiro Hara (MD, PhD, FJCC) Division of Cardiology and Cardiovascular Surgery, Mitsui Memorial Hospital, 1 Kanda-Izumicho, Chiyoda-ku, Tokyo 101-8643, Japan
a r t i c l e
i n f o
Article history: Received 7 July 2012 Received in revised form 28 December 2012 Accepted 12 February 2013 Keywords: Multidetector computed tomography Echocardiography Aortic dissection Aortic regurgitation Back-and-forth intimal flap movement
a b s t r a c t A 46-year-old man with a history of hypertension, chronic kidney disease, and chronic aortic dissection classified as DeBakey type IIIB was referred to our hospital with chest and back pain. The patient underwent 64-row multidetector computed tomography (MDCT), which revealed new-onset DeBakey type II aortic dissection. The intimal flap prolapsed into left ventricle in the diastolic phase of cardiac cycle and stuck to the right coronary cusp (RCC) of the aortic valve. He also underwent transesophageal echocardiography (TEE) to assess the relationship between the intimal flap and aortic valve in detail. The intimal flap overlaid the RCC and prolapsed into the left ventricle outflow tract in the diastolic phase. These images suggested that the circumferential intimal flap stuck to the aortic valve, resulting in severe aortic regurgitation. One day after the admission, the patient underwent replacement of ascending aorta with a prosthetic graft. Intraoperative observation exhibited the intimal flap inverted to the left ventricle. MDCT could detect the flat movement, as well as TEE, in addition to the extent of aortic dissection. © 2013 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
Introduction Acute aortic regurgitation is a well-recognized complication that occurs in patients with aortic dissection involving the ascending aorta. However, diastolic prolapse of the aortic intimal flap into the left ventricle is a rare cause of aortic regurgitation [1]. We report here a case of aortic dissection with severe aortic regurgitation due to back-and-forth intimal flap movement detected by both multidetector computed tomography (MDCT) and transesophageal echocardiography (TEE). Case report A 46-year-old man with a history of hypertension, chronic kidney disease, and chronic aortic dissection classified as DeBakey type
∗ Corresponding author. Tel.: +81 3 3862 9111; fax: +81 3 3862 0023. E-mail address: [email protected] (K. Tanabe).
IIIB was referred to our hospital with chest and back pain lasting for two days. The heart rate was 120 beats per minute and blood pressure in the right arm was 136/60 mmHg, with no significant difference from left arm. The patient also had congestive heart failure. There was not ischemic manifestation, such as electrocardiographic change and wall motion abnormality in transthoracic echocardiography (TTE). An intimal flap in proximal ascending aorta and severe aortic regurgitation were observed by TTE. We suspected that chronic aortic dissection extended to proximal ascending aorta. The patient underwent 64-row MDCT, which revealed new-onset DeBakey type II aortic dissection (Fig. 1A and B). The intimal flap prolapsed into left ventricle in the diastolic phase of cardiac cycle and stuck to the right coronary cusp (RCC) of the aortic valve (Fig. 2A and Supplementary video 1) [2]. The flap did not involve the ostia of coronary arteries (Fig. 1C). He also underwent TEE to assess the relationship between the intimal flap and aortic valve in detail. The intimal tear was located just above the sino-tubular junction and extended to the commissure between noncoronary cusp (NCC) and RCC (Fig. 1D). The intimal flap overlay the RCC and prolapsed into
1878-5409/$ – see front matter © 2013 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jccase.2013.02.006
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Fig. 1. MDCT revealed acute ascending aortic dissection (arrows) and chronic descending aortic dissection (arrow heads) (A, B). MDCT showed that the ostia of coronary arteries were not involved with the intimal flap (C). Transesophageal echocardiographic short-axis image of ascending aorta showed a proximal aortic dissection with a circumferential intimal flap located just above the sino-tubular junction and extended to the commissure between noncoronary cusp and right coronary cusp (D). In operation, the intimal flap was inverted to the left ventricle (E). A-Ao, ascending aorta; D-Ao, descending aorta; LMCA, left main coronary artery; MDCT, multidetector computed tomography; RCA, right coronary artery; NCC, noncoronary cusp; RCC, right coronary cusp; LCC, left coronary cusp; LV, left ventricle.
Fig. 2. MDCT (A) and TEE (B) in long-axis image showed back-and-forth movements of the intimal flap. The intimal flap projected into proximal ascending aorta in the systolic phase (the left panel). In diastole, right coronary cusp of aortic valve was stuck by prolapsed intimal flap (the right panel). LV, left ventricle; MDCT, multidetector computed tomography; TEE, transesophageal echocardiography.
H. Hara et al. / Journal of Cardiology Cases 7 (2013) e161–e163
the left ventricle outflow tract in the diastolic phase (Fig. 2B and Supplementary video 2). These images suggested that the circumferential intimal flap stuck to the aortic valve, resulting in severe aortic regurgitation (Supplementary video 3) [1]. One day after the admission, the patient underwent resuspension of the commissure between NCC and RCC and replacement of ascending aorta with a prosthetic graft. Intraoperative observation exhibited the entry of proximal ascending aorta and the intimal flap inverted to the left ventricle (Fig. 1E) [3,4]. The surgery was successfully performed without any complications and aortic regurgitation was improved. The patient was discharged 41 days after the operation. See Videos 1–3 as supplementary files. Supplementary material related to this article found, in the online version, at http://dx.doi.org/10.1016/j.jccase.2013.02.006. Discussion To the best of our knowledge, our case was the first case that included surgical findings as well as images obtained by MDCT and TEE. The mortality rate of acute aortic dissection involving the ascending aorta is about 1% per hour for the first 24 h. After 48 h, the mortality rate is gradually reduced [5]. Emergent surgery was recommended. However, in our case, the surgeons were occupied when the diagnosis was made. The onset was two days previously, therefore, the surgery was performed after experienced surgeons were available. Acute aortic regurgitation is a complication that occurs in patients with aortic dissection involving the ascending aorta. Aortic regurgitation may result from three different mechanisms: (1) the dissection may cause progressive aortic root and annular dilatation, which prevents central leaflet coaptation; (2) the dissection may disturb the aortic root geometry in an asymmetric fashion, with consequent prolapse of one leaflet; and (3) diastolic prolapse of the intimal flap into the left ventricle, which sticks to the aortic valve [1]. In this case, the entry was at the proximal site of
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the ascending aorta and circumferential dissection extended both anterogradely and retrogradely. Severe aortic regurgitation was due to prolapse of the intimal flap into the left ventricle and also due to the prolapse of the commissure between the NCC and RCC. The ascending aorta was transected just above the sino-tubular junction and the false lumen of the aortic root was approximated using gelatin–resorcine–formaldehyde glue. The commissure between NCC and RCC was resuspended and the ascending aorta was replaced with the prosthetic graft. Aortic regurgitation was not detected postoperatively. A prolapsed intimal flap can cause myocardial ischemia and cardiogenic shock by obstruction of the ostia of coronary arteries during diastole [6]. In our case, there was neither ischemic electrocardiographic change nor wall motion abnormality in TTE at rest. Further, the ostia of coronary arteries were evaluated by both MDCT and TEE, which demonstrated patency. MDCT could detect the flat movement, as well as TEE, in addition to the extent of aortic dissection. References [1] Ko SM. MDCT findings of acute aortic dissection with diastolic prolapse of the intimal flap into the left ventricle. Br J Radiol 2009;82:e95–7. [2] Movsowitz HD, Levine RA, Hilgenberg AD, Isselbacher EM. Transesophageal echocardiographic description of the mechanisms of aortic regurgitation in acute type A aortic dissection: implications for aortic valve repair. J Am Coll Cardiol 2000;36:884–90. [3] Nohara H, Shida T, Mukohara N, Nakagiri K, Matsumori M, Ogawa K. Aortic regurgitation secondary to back-and-forth intimal flap movement of acute type A dissection. Ann Thorac Cardiovasc Surg 2004;10:54–6. [4] Oguz E, Apaydin AZ, Nalbantgil S, Engin C, Ayik F. Circumferential intimal flap prolapsing into the left ventricle. Tex Heart Inst J 2007;34: 496–7. [5] Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh JK, Moore AG, Malouf JF, Pape LA, Gaca C, Sechtem U, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897–903. [6] Sato Y, Satokawa H, Takase S, Misawa Y, Yokoyama H. Prolapse of aortic intimal flap into the left ventricle: a rare cause of global myocardial ischemia in acute type A aortic dissection. Circ J 2006;70:214–5.
Contents lists available at www.sciencedirect.com
Journal of Cardiology Cases journal homepage: www.elsevier.com/locate/jccase
Case Report
Aortic regurgitation due to back-and-forth intimal flap movement detected by both multidetector computed tomography and transesophageal echocardiography Hironori Hara (MD), Kengo Tanabe (MD, PhD) ∗ , Shuzou Tanimoto (MD, PhD), Jiro Aoki (MD, PhD), Sen Yachi (MD), Satoru Kishi (MD), Hiroyoshi Nakajima (MD, PhD, FJCC), Takeshi Miyairi (MD, PhD), Kazuhiro Hara (MD, PhD, FJCC) Division of Cardiology and Cardiovascular Surgery, Mitsui Memorial Hospital, 1 Kanda-Izumicho, Chiyoda-ku, Tokyo 101-8643, Japan
a r t i c l e
i n f o
Article history: Received 7 July 2012 Received in revised form 28 December 2012 Accepted 12 February 2013 Keywords: Multidetector computed tomography Echocardiography Aortic dissection Aortic regurgitation Back-and-forth intimal flap movement
a b s t r a c t A 46-year-old man with a history of hypertension, chronic kidney disease, and chronic aortic dissection classified as DeBakey type IIIB was referred to our hospital with chest and back pain. The patient underwent 64-row multidetector computed tomography (MDCT), which revealed new-onset DeBakey type II aortic dissection. The intimal flap prolapsed into left ventricle in the diastolic phase of cardiac cycle and stuck to the right coronary cusp (RCC) of the aortic valve. He also underwent transesophageal echocardiography (TEE) to assess the relationship between the intimal flap and aortic valve in detail. The intimal flap overlaid the RCC and prolapsed into the left ventricle outflow tract in the diastolic phase. These images suggested that the circumferential intimal flap stuck to the aortic valve, resulting in severe aortic regurgitation. One day after the admission, the patient underwent replacement of ascending aorta with a prosthetic graft. Intraoperative observation exhibited the intimal flap inverted to the left ventricle. MDCT could detect the flat movement, as well as TEE, in addition to the extent of aortic dissection.
Introduction Acute aortic regurgitation is a well-recognized complication that occurs in patients with aortic dissection involving the ascending aorta. However, diastolic prolapse of the aortic intimal flap into the left ventricle is a rare cause of aortic regurgitation [1]. We report here a case of aortic dissection with severe aortic regurgitation due to back-and-forth intimal flap movement detected by both multidetector computed tomography (MDCT) and transesophageal echocardiography (TEE). Case report A 46-year-old man with a history of hypertension, chronic kidney disease, and chronic aortic dissection classified as DeBakey type
∗ Corresponding author. Tel.: +81 3 3862 9111; fax: +81 3 3862 0023. E-mail address: [email protected] (K. Tanabe).
IIIB was referred to our hospital with chest and back pain lasting for two days. The heart rate was 120 beats per minute and blood pressure in the right arm was 136/60 mmHg, with no significant difference from left arm. The patient also had congestive heart failure. There was not ischemic manifestation, such as electrocardiographic change and wall motion abnormality in transthoracic echocardiography (TTE). An intimal flap in proximal ascending aorta and severe aortic regurgitation were observed by TTE. We suspected that chronic aortic dissection extended to proximal ascending aorta. The patient underwent 64-row MDCT, which revealed new-onset DeBakey type II aortic dissection (Fig. 1A and B). The intimal flap prolapsed into left ventricle in the diastolic phase of cardiac cycle and stuck to the right coronary cusp (RCC) of the aortic valve (Fig. 2A and Supplementary video 1) [2]. The flap did not involve the ostia of coronary arteries (Fig. 1C). He also underwent TEE to assess the relationship between the intimal flap and aortic valve in detail. The intimal tear was located just above the sino-tubular junction and extended to the commissure between noncoronary cusp (NCC) and RCC (Fig. 1D). The intimal flap overlay the RCC and prolapsed into
1878-5409/$ – see front matter © 2013 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jccase.2013.02.006
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H. Hara et al. / Journal of Cardiology Cases 7 (2013) e161–e163
Fig. 1. MDCT revealed acute ascending aortic dissection (arrows) and chronic descending aortic dissection (arrow heads) (A, B). MDCT showed that the ostia of coronary arteries were not involved with the intimal flap (C). Transesophageal echocardiographic short-axis image of ascending aorta showed a proximal aortic dissection with a circumferential intimal flap located just above the sino-tubular junction and extended to the commissure between noncoronary cusp and right coronary cusp (D). In operation, the intimal flap was inverted to the left ventricle (E). A-Ao, ascending aorta; D-Ao, descending aorta; LMCA, left main coronary artery; MDCT, multidetector computed tomography; RCA, right coronary artery; NCC, noncoronary cusp; RCC, right coronary cusp; LCC, left coronary cusp; LV, left ventricle.
Fig. 2. MDCT (A) and TEE (B) in long-axis image showed back-and-forth movements of the intimal flap. The intimal flap projected into proximal ascending aorta in the systolic phase (the left panel). In diastole, right coronary cusp of aortic valve was stuck by prolapsed intimal flap (the right panel). LV, left ventricle; MDCT, multidetector computed tomography; TEE, transesophageal echocardiography.
H. Hara et al. / Journal of Cardiology Cases 7 (2013) e161–e163
the left ventricle outflow tract in the diastolic phase (Fig. 2B and Supplementary video 2). These images suggested that the circumferential intimal flap stuck to the aortic valve, resulting in severe aortic regurgitation (Supplementary video 3) [1]. One day after the admission, the patient underwent resuspension of the commissure between NCC and RCC and replacement of ascending aorta with a prosthetic graft. Intraoperative observation exhibited the entry of proximal ascending aorta and the intimal flap inverted to the left ventricle (Fig. 1E) [3,4]. The surgery was successfully performed without any complications and aortic regurgitation was improved. The patient was discharged 41 days after the operation. See Videos 1–3 as supplementary files. Supplementary material related to this article found, in the online version, at http://dx.doi.org/10.1016/j.jccase.2013.02.006. Discussion To the best of our knowledge, our case was the first case that included surgical findings as well as images obtained by MDCT and TEE. The mortality rate of acute aortic dissection involving the ascending aorta is about 1% per hour for the first 24 h. After 48 h, the mortality rate is gradually reduced [5]. Emergent surgery was recommended. However, in our case, the surgeons were occupied when the diagnosis was made. The onset was two days previously, therefore, the surgery was performed after experienced surgeons were available. Acute aortic regurgitation is a complication that occurs in patients with aortic dissection involving the ascending aorta. Aortic regurgitation may result from three different mechanisms: (1) the dissection may cause progressive aortic root and annular dilatation, which prevents central leaflet coaptation; (2) the dissection may disturb the aortic root geometry in an asymmetric fashion, with consequent prolapse of one leaflet; and (3) diastolic prolapse of the intimal flap into the left ventricle, which sticks to the aortic valve [1]. In this case, the entry was at the proximal site of
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the ascending aorta and circumferential dissection extended both anterogradely and retrogradely. Severe aortic regurgitation was due to prolapse of the intimal flap into the left ventricle and also due to the prolapse of the commissure between the NCC and RCC. The ascending aorta was transected just above the sino-tubular junction and the false lumen of the aortic root was approximated using gelatin–resorcine–formaldehyde glue. The commissure between NCC and RCC was resuspended and the ascending aorta was replaced with the prosthetic graft. Aortic regurgitation was not detected postoperatively. A prolapsed intimal flap can cause myocardial ischemia and cardiogenic shock by obstruction of the ostia of coronary arteries during diastole [6]. In our case, there was neither ischemic electrocardiographic change nor wall motion abnormality in TTE at rest. Further, the ostia of coronary arteries were evaluated by both MDCT and TEE, which demonstrated patency. MDCT could detect the flat movement, as well as TEE, in addition to the extent of aortic dissection. References [1] Ko SM. MDCT findings of acute aortic dissection with diastolic prolapse of the intimal flap into the left ventricle. Br J Radiol 2009;82:e95–7. [2] Movsowitz HD, Levine RA, Hilgenberg AD, Isselbacher EM. Transesophageal echocardiographic description of the mechanisms of aortic regurgitation in acute type A aortic dissection: implications for aortic valve repair. J Am Coll Cardiol 2000;36:884–90. [3] Nohara H, Shida T, Mukohara N, Nakagiri K, Matsumori M, Ogawa K. Aortic regurgitation secondary to back-and-forth intimal flap movement of acute type A dissection. Ann Thorac Cardiovasc Surg 2004;10:54–6. [4] Oguz E, Apaydin AZ, Nalbantgil S, Engin C, Ayik F. Circumferential intimal flap prolapsing into the left ventricle. Tex Heart Inst J 2007;34: 496–7. [5] Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh JK, Moore AG, Malouf JF, Pape LA, Gaca C, Sechtem U, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897–903. [6] Sato Y, Satokawa H, Takase S, Misawa Y, Yokoyama H. Prolapse of aortic intimal flap into the left ventricle: a rare cause of global myocardial ischemia in acute type A aortic dissection. Circ J 2006;70:214–5.