Aortic Regurgitation Due to Fibrous Strand Rupture in the Fenestrated Left Coronary Cusp of the Tricuspid Aortic Valve

Abstract Clinical case 59 years old male known case of long standing diabetes and dyslipidemia presented to our institute with Non-STEMI.His past history was significant for multiple admissions with acute coronary syndromes and percutaneous coronary interventions(PCI). Echocardiogram in this presentation showed preserved biventricular systolic function with no valvulopathies. He was taken up for coronary angiogram which showed significant calcified angulated lesion in LAD/LCX(Left anterior descending and circumflex) with diffuse disease in Ramus/RCA. Mode of revascularisation was discussed in detail with the patient for Rotablation-guided PCI to LAD/LCX vs CABG.He preferred and underwent complex PCI to LAD. During the procedure he developed acute heart failure which was managed conservatively. Immediate TTE showed new severe aortic regurgitation(AR) with probable left coronary cusp(LCC) perforation and preserved LVEF.After stabilization, he was scheduled for TEE which showed tear in the LCC with complex fragmented jet of holodiastolic AR filling the entire LVOT.There was new late diastolic to early systolic MR.3DTEE Enface view of the aortic valve was evident of ovoid shaped laceration in LCC extending till the free margin (Fig 1C). There were additional tears in Non-coronary cusp(NCC) extending till the free margin of right coronary cusp(RCC).3DTEE colour was notable for regurgitant jet origin from LCC/NCC (Fig 2B). Based on above findings,He was offered aortic valve intervention but was reluctant initially.He presented 2 months later with exertional dyspnoea, mild LV dilatation and drop in LVEF to 50%.He consented for surgery and underwent bioprosthetic Aortic valve replacement because of extensive cusp tear and deformation of the valve along with complete revascularisation of the remaining diseased coronaries.Post-operative course was complicated by vasoplegic arrest and acute renal failure which was successfully managed conservatively. Discussion We report this case for the rarity of this post-PCI iatrogenic complication and the incremental role of 3DTEE in identifying the exact pathology.It was proposed that during PCI multiple stalling of rotatbur in calcified LAD caused traction and eventually disengagement of guide causing rotabur to freely hang in ascending aorta close to the cusps.Possibly this rotablator with very high speed(180000rpm) would have momentarily come in contact with the aortic cusps causing cuspal perforation and heart failure in Cath lab.3DTEE correlated very well with the anatomo-pathology and matched with intraoperative finding as shown in figures 2A & 2C.These findings prior to aortic cross clamp could significantly reduce time of surgery as he had an additional CABG procedure to be performed.There are few isolated case reports of post PCI aortic valve perforation but probably ours is the first one secondary to the use of rotablator with near involvement of all the cusps and reasonably accurate 3DTEE-anatomic characterisation. Abstract P249 Figure.

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Aortic regurgitation caused by fibrous strand rupture in a fenestrated aortic valve

Journal of Echocardiography ◽

10.1007/s12574-012-0148-7 ◽

2012 ◽

Vol 10 (4) ◽

pp. 151-153

Author(s):

Kazumi Akasaka ◽

Erika Saito ◽

Takaya Higuchi ◽

Takako Yanagiya ◽

Rie Nakamori ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Fibrous Strand

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Acute aortic regurgitation following fibrous strand rupture of aortic valve successfully diagnosed by transesophageal echocardiography

Echocardiography ◽

10.1111/echo.13882 ◽

2018 ◽

Vol 35 (5) ◽

pp. 753-754

Author(s):

Hidefumi Nishida ◽

Etsuro Suenaga ◽

Katsuhisa Ishii

Keyword(s):

Aortic Valve ◽

Transesophageal Echocardiography ◽

Aortic Regurgitation ◽

Fibrous Strand

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Asymmetric aortic valve is related to development of eccentric aortic regurgitation in patients with tricuspid aortic valve

Echocardiography ◽

10.1111/echo.14374 ◽

2019 ◽

Vol 36 (6) ◽

pp. 1035-1040

Author(s):

Tae‐Ho Park ◽

Soo‐Jin Kim ◽

Young‐Rak Cho ◽

Kyungil Park ◽

Jong‐Sung Park ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Tricuspid Aortic Valve

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Aortic regurgitation is not created equal: outcomes of bicuspid versus tricuspid aortic valve regurgitation

European Heart Journal ◽

10.1093/ehjci/ehaa946.0052 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

L.T Yang ◽

G Benfari ◽

V.T Nkomo ◽

M Enriquez-Sarano ◽

P.A Pellikka ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Negative Impact ◽

Left Ventricular ◽

Functional Class ◽

Class I ◽

Poor Survival ◽

Tricuspid Aortic Valve ◽

Cohort Differences

Abstract Background Bicuspid aortic valve (BAV) is an important cause of AR; these patients belong to a young and male predominant population and are distinctively different from tricuspid aortic valve (TAV). However, the differences between BAV and TAV in AR have not been completely explored. Purpose To explore differences between patients with BAV and TAV in hemodynamically significant aortic regurgitation (AR). Methods Consecutive patients with ≥moderate-severe AR were retrospectively identified from 2006 to 2017. Results Of 798 patients (502 with TAV, mean age 67±14 years; 296 with BAV, mean age 46±14 years) followed for 6.1±3.6 years, 403 underwent AV surgery (AVS); 154 died during follow-up. BAV men (94%) tended to become symptomatic when left ventricle enlarged; TAV patients became symptomatic before left ventricular (LV) enlargement. During follow-up, BAV patients had lower mortality (hazard ratio [HR], 0.19; P<0.0001) and higher incidence of AVS (HR, 1.28; P=0.01) than TAV, which attenuated after adjusted on age, sex, comorbidities, LV ejection fraction (LVEF), functional class, and time-dependent AVS. In a propensity-matched cohort, differences of survival and incidence of AVS between BAV and TAV were not demonstrated. After a median of 6.3 (IQR: 3.3–9.3) years, 53 patients died post-AVS; TAV patients having class I surgical triggers had poor survival than TAV-non-class I patients and BAV patients with and without class I triggers (Figure). Class I triggers had no effect on BAV patients regarding post-AVS survival. LVEF<60% was associated with increased mortality in both TAV and BAV. Conclusions The correlation between larger LV size and symptomatic status only applied in BAV men. Patients with BAV and significant AR tended to have better survival and higher incidence of AVS, likely driven by inherent younger age and less comorbidity than patients with TAV. Class I surgical triggers had heavier negative impact on poor survival in TAV patients. The cutoff of LV dysfunction in AR may be LVEF 60%. Figure 1. Kaplan-Meier curves post-AVS Funding Acknowledgement Type of funding source: None

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P5583Micro-movement during transcatheter aortic valve implantation with a contemporary self-expandable prosthesis

European Heart Journal ◽

10.1093/eurheartj/ehz746.0527 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

K Hellhammer ◽

K Piayda ◽

V Veulemans ◽

S Afzal ◽

I Hennig ◽

...

Keyword(s):

Risk Factor ◽

Aortic Valve ◽

Aortic Regurgitation ◽

Aortic Valve Area ◽

Transcatheter Aortic Valve ◽

Aortic Valve Implantation ◽

Coronary Cusp ◽

Valve Implantation ◽

Valve Area

Abstract Background Precise positioning of the prosthesis is a crucial step during transcatheter aortic valve implantation. In some cases, contemporary self-expandable prostheses show micro-movement (MM) during the final phase of release. Purpose We aimed to establish a definition for MM, evaluated the incidence of MM using the CoreValve Evolut RTM, investigated potential risk factors for MM and the associated clinical outcomes. Methods MM was defined as movement of the prosthesis of at least 1.5 mm from its position directly before release compared to its final position. Patients were grouped according to the occurrence (+MM) or absence (-MM) of MM. Baseline characteristics, imaging data and outcome parameters in accordance with the updated valve academic research consortium (VARC-2) criteria were retrospectively analyzed. Results We identified 258 eligible patients. MM occurred in 31.8% (n=82) of cases with a mean magnitude of 2.8±2.2 mm in relation to the left coronary cusp and 3.0±2.1 mm to the non-coronary cusp. Clinical and hemodynamic outcomes were similar in both groups. The mean pressure gradient was effectively reduced after TAVI (-MM vs. +MM: 7±3.4 mmHg vs. 8±3.9 mmHg, p=0.326) with consistency over a follow-up period of at least three months (-MM vs. +MM: 6.7±3.7 mmHg vs. 7.9±8.4 mmHg, p=0.168). At three months follow-up most of the patients presented with no aortic regurgitation (-MM vs. +MM: 64% vs. 67.9%, p=0.569). Mild aortic regurgitation was observed in 34.2% of the -MM group and in 29.5% of the +MD group (p=0.414). Moderate aortic regurgitation occurred in 1.9% of all patients with no differences between groups (-MM vs. +MM: 1.9% vs. 2.6%, p=0.662). Patients with MM presented with a more symmetric calcification pattern (-MM vs. +MM: 27.3% vs. 40.2%; p=0.037) and a larger aortic valve area (-MM vs. +MM: 0.6 cm2 ± 0.3 vs. 0.7 cm2 ± 0.2; p=0.014), which was found to be a potential risk factor for the occurrence of MM in a multivariate regression analysis (OR 3.5; 95% CI: 1.1–10.9; p=0.032) Conclusion MM occurred in nearly one third of patients and did not affect clinical and hemodynamic outcome. A larger aortic valve area was the only independent risk factor for the occurrence of MM.

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Faculty Opinions recommendation of Two decades of valve-sparing root reimplantation in tricuspid aortic valve: impact of aortic regurgitation and cusp repair.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.739235169.793581439 ◽

2020 ◽

Author(s):

John Augoustides

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Tricuspid Aortic Valve ◽

Valve Sparing

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Contemporary differences between bicuspid and tricuspid aortic valve in chronic aortic regurgitation

Heart ◽

10.1136/heartjnl-2020-317466 ◽

2020 ◽

pp. heartjnl-2020-317466

Author(s):

Li-Tan Yang ◽

Giovanni Benfari ◽

Mackram Eleid ◽

Christopher G Scott ◽

Vuyisile T Nkomo ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Real Life ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Tertiary Referral Centre ◽

Ventricular Ejection Fraction ◽

Tricuspid Aortic Valve ◽

Risk Of Death ◽

Chronic Aortic Regurgitation

ObjectiveTo comprehensively explore contemporary differences between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients with chronic haemodynamically significant aortic regurgitation (AR).MethodsConsecutive patients with chronic ≥moderate-severe AR from a tertiary referral centre (2006–2017) were included. All-cause mortality, surgical indications and aortic valve surgery (AVS) were analysed.ResultsOf 798 patients (296 BAV-AR, age 46±14 years; 502 TAV-AR, age 67±14 years, p<0.0001) followed for 5.5 (IQR: 2.9–9.2) years, 403 underwent AVS (repair in 96) and 154 died during follow-up. The 8-year AVS incidence was 60%±3% versus 53%±3% for BAV-AR and TAV-AR, respectively (p=0.014). The unadjusted (real-life) 8-year total survival was 93%±7% versus 71%±2% for BAV-AR and TAV-AR, respectively (p<0.0001), and became statistically insignificant after sole adjustment for age (p=0.14). The within-group relative risk of death in BAV-AR patients demonstrated a large age-dependent increase (two fold at 50–55 years, up to 10-fold at 70 years). The presence of baseline symptoms was significantly associated with death for both BAV-AR (p=0.039) and TAV-AR (p<0.0001), but the strength of the association decreased with age adjustment for BAV-AR (age-adjusted HR 2.43 (0.92–6.39), p=0.07) and not for TAV-AR (age-adjusted HR, 2.3 (1.6–3.3), p<0.0001). As compared with general population, TAV-AR exhibited baseline excess risk which further increased at left ventricular ejection fraction (LVEF) <60% and left ventricular end-systolic dimension index (LVESDi) >20 mm/m2; similar thresholds were observed for BAV-AR patients.ConclusionBAV-AR patients were two decades younger than TAV-AR and underwent AVS more frequently, resulting in a considerable real-life survival advantage for BAV-AR that was determined primarily by age and not valve anatomy. Pragmatically, regardless of valve anatomy, patients with haemodynamically significant AR and age >50–55 years require a low-threshold for surgical referral to prevent symptom development where LVEF <60% and LVESDi >20 mm/m2 seem appropriate referral thresholds.

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