Painless limited dissection of the ascending aorta presenting with aortic valve regurgitation

Aortic dissection is a medical emergency carrying high morbidity and mortality. Prompt diagnosis is sometimes difficult because of its varying presentations, but it is critical to the achievement of good clinical outcomes. This report describes 2 cases of painless aortic dissection that presented with aortic valve regurgitation. In both, the dissection was limited to the ascending aorta just distal to the aortic valve. These dissections were diagnosed by transthoracic and transesophageal echocardiography.     

Bicuspid aortic valve stenosis complicated by descending aortic dissection mimicking coarctation of the aorta.

We report a rare case of bicuspid aortic stenosis complicated by an ascending aortic aneurysm and aortic dissection of DeBakey type IIIb. A 35-year-old woman was admitted to our hospital to examine her systolic murmur identified at birth. Severe aortic stenosis, dilatation of the ascending aorta, and the narrow color flow signal in the descending aorta were detected by transthoracic echocardiography. Initially, coarctation of the descending aorta was suspected, but aortic dissection, DeBakey type IIIb, was revealed by transesophageal echocardiography. Transesophageal echocardiography is indicated when only insufficient information is available on valve and aortic morphology in patients with bicuspid aortic valve.     

A case of iatrogenic aortic valve leaflet perforation after closure of a ventricular septal defect

Aortic regurgitation caused by leaflet perforation is most frequently seen in association with infective endocarditis that involves the aortic valve. There have been occasional reports of iatrogenic aortic regurgitation caused by aortic valve injury after cardiac surgery with the use of the transaortic approach or invasive cardiac procedures. Suture-related aortic valve injury can develop during periaortic cardiac surgery, but this has been very rarely reported. Inadvertent injury to an aortic valve leaflet caused by a stitching needle or surgical forceps can produce leaflet perforation with aortic regurgitation. This report describes a case of aortic regurgitation that was caused by iatrogenic aortic valve leaflet perforation, and this occurred in a 22-year-old woman who underwent repair of a ventricular septal defect (VSD) 15 years previously. Transthoracic echocardiography (TTE) showed a defect located at the aortic annulus close to the infundibular septum on a two-dimensional echocardiographic study and we observed an eccentric jet flow into the left ventricle in early diastole on the continuous wave and color flow Doppler studies. A small perforation in the body of the right aortic cusp and mild to moderate aortic regurgitation were confirmed by the use of transesophageal echocardiography (TEE) and ascending aortography.     

Asymptomatic dissection of the ascending aorta: diagnosis by transesophageal echocardiography

A young man with marfanoid habitus underwent transesophageal echocardiography to evaluate an aortic root abnormality visualized on transthoracic echocardiography. Transesophageal echo demonstrated a type A aortic dissection traversing across the right sinus of Valsalva but not involving the aortic valve, right coronary artery, or pericardial sac. The aorta was not dilated. This is apparently the first reported case of an asymptomatic and uncomplicated aortic dissection localized to the sinus of Valsalva.     

Intraoperative transesophageal echocardiographic assessment of acute prosthetic aortic valve regurgitation after mitral valve replacement: Value of the deep transgastric long-axis view

The transesophageal echocardiographic assessment of prosthetic aortic valve function is made more difficult by the presence of a mechanical mitral valve prosthesis because echocardiographic views conventionally used to assess the aortic valve function are obscured by acoustic shadowing and artifacts. We report the use of intraoperative transesophageal echocardiography in a patient who developed severe prosthetic aortic valve regurgitation after implantation of a mechanical mitral valve, in whom conventional multiplane midesophageal views failed to reveal aortic regurgitation owing to acoustic shadowing and artifacts from the prosthetic mitral valve. We report the value of the deep transgastric long-axis view of the aortic valve that provided an unobstructed view of the left-ventricular outflow tract, and clearly demonstrated severe aortic regurgitation as a result of interference with the prosthetic aortic valve mechanism by the implanted mitral valve prosthesis. This case also emphasizes the importance of a comprehensive intraoperative transesophageal examination, including that of surrounding structures, to detect iatrogenic complications during mitral valve replacement.     

Utility of transesophageal echocardiography for the characterization of cardiovascular anomalies associated with Turner's syndrome.

This case illustrates the complementary value of transesophageal echocardiography to routine transthoracic echocardiography in an asymptomatic adult patient with Turner's syndrome. The combined findings of bicuspid aortic valve, severe aortic dilation, coarctation of the aorta, and type A aortic dissection were clearly delineated by transesophageal echocardiography.     

Dissection of the proximal thoracic aorta: a new ultrasonographic sign in the subxiphoid view

Dissection of the thoracic aorta is a life-threatening event that presents with some regularity to emergency departments (EDs). Despite often nonspecific symptoms, it is critical to catch this disease process early, especially when the proximal aorta is involved because dissections involving the aortic root can lead to myocardial infarction and failure of the aortic valve resulting in death. Current imaging options include contrast-enhanced chest computed tomography (CT), angiography, magnetic resonance imaging, or transesophageal echocardiography. Although not as accurate as transesophageal echocardiography, transthoracic echocardiography (TTE) can be used to detect aortic dissection as well. We present a previously undescribed echocardiographic finding associated with proximal dissection of the thoracic aorta in 7 cases.     

二维、三维经食管超声心动图在经导管主动脉瓣植入术中的应用价值

目的探讨二维、三维经食管超声心动图在经导管主动脉瓣植入术（TAVI）中的应用价值。 方法对2010年5月至2015年10月在复旦大学附属中山医院行TAVI的11例重度主动脉瓣狭窄[主动脉瓣狭窄口面积<1.0 cm²,主动脉瓣口最大流速>4 m/s,平均跨瓣压差>40 mmHg（1 mmHg=0.133 kPa）]和1例人工生物主动脉瓣中重度反流患者术前均行常规经胸超声心动图检查及二维、三维经食管超声心动图检查（2DTEE、3DTEE）,术中二维、三维经食管超声心动图监测,术后常规经胸超声心动图随访。采用Pearson相关分析分析3DTEE与计算机断层扫描（MDCT）评价主动脉瓣环最大值、最小值、瓣环面积以及狭窄口面积的相关性及3DTEE、MDCT与连续性方程评价狭窄口面积的相关性。 结果所有患者均成功植入人工生物主动脉瓣,其中1例患者术中发现心脏压塞合并升主动脉夹层分离,经心包穿刺以及升主动脉夹层分离保守治疗3 d后突发心脏压塞死亡。所有患者MDCT与3DTEE评价主动脉瓣环最大径、最小径、瓣环面积及狭窄口面积的相关性均较好（r=0.98、0.97、0.97、0.99,P均<0.01）;术前连续性方程测量的主动脉狭窄口面积与MDCT及3DTEE评价结果的相关性均很好（r值均为0.99,P均<0.01）。 结论2DTEE、3DTEE能快速、准确地定量主动脉瓣环的大小及评价主动脉的解剖结构,能实时引导和监测经导管主动脉瓣植入及其并发症。     

Aortic dissection with fistula to left atrium: diagnosis by transesophageal echocardiography with successful repair.

The aorta-atria fistula is an infrequent complication of aortic dissection, and it is rarely diagnosed before death. A 41-year-old man who 8 years previously had undergone prosthetic aortic valve replacement had an aortic dissection complicated by aorta-left atrial fistula. This patient had acute left heart failure associated with a systolic and diastolic murmur at the lower left sternal border suggesting an aortic prosthetic malfunction. The cardiac diagnosis was made with transesophageal echocardiography and Doppler color flow imaging; it was notable that the cardiac lesions were not detected by transthoracic echocardiography. On the basis of the echocardiographic findings, the patient underwent successful emergency replacement of the dissecting ascending aorta with closure of the aorta-left atrial fistula. Transesophageal echocardiography is the procedure of choice for defining this abnormality. In this case a prompt surgical repair consisting of replacement of the affected segment of the aorta with the prosthesis and closure of the fistula provided optimum resolution of the clinical situation.     

Spontaneous Aortic Laceration Causing Flail Aortic Valve and Acute Aortic Regurgitation

Spontaneous laceration of the aorta is an unusual cause of flail aortic valve. We report a case of acute aortic regurgitation caused by flail aortic valve as a result of spontaneous laceration of the ascending aorta. The role of transesophageal echocardiography in the diagnosis of this condition is discussed. (J Am Soc Echocardiogr 1999;12:76-8.)     

高血压对主动脉根部管径及主动脉瓣返流的影响

目的：确定主动脉根部管径及其与高血压、主动脉瓣返流的联系。方法：应用二维超声心动图对52例临床确诊为高血压患者和54例正常成人的主动脉根部管径于4个水平分别进行测量。利用彩色多普勒观察主动脉瓣口有无返流。结果：高血压患者主动脉上嵴及升主动脉近段管径显著增加,主动脉瓣返流率较正常血压组显著增高。结论：高血压可使主动脉根部远段部分增宽,并可能导致了主动脉瓣的返流,对早期诊断心衰、降低死亡率具有重要意义。     

Large Ascending Aortic Aneurysm and Severe Aortic Regurgitation in a 7-year-Old Child with Marfan Syndrome and a Review of the Literature: Marfan Syndrome in Childhood

A 7-year-old girl was admitted because of dyspnea on exertion and palpitations. Her symptoms had gradually worsened for the last 6 months. She had physical features of the Marfan syndrome. Transthoracic echocardiography showed an ascending aortic aneurysm, severe aortic regurgitation, and mildly dilated left ventricle. Because of marked aortic aneurysm and severe aortic regurgitation, the patient was treated with a beta-blocker and an angiotensin converting enzyme inhibitor. Surgery was refused by her parents. We describe here a child with Marfan syndrome in whom significant dilatation of the ascending aorta and severe aortic regurgitation is encountered and major cardiovascular complications of Marfan syndrome were reviewed.     

Coexistence of multiple and widespread cardiovascular complications in a patient with Marfan syndrome

Inherited connective tissue diseases such as Marfan syndrome are frequently associated with cardiovascular manifestations. Aortic involvement with dilation and dissection is the most common finding and the major cause of death in Marfan syndrome patients. We report the echocardiographic study of a 53‐year‐old male patient with uncommon coexistence of cardiovascular abnormalities typical of connective tissue disease at first clinical presentation in acute clinical setting: dissection of the descending aorta associated with severe mitral regurgitation due to leaflet flail and massive aortic insufficiency due to ascending aortic enlargement, leading to left ventricular dilation and dysfunction. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2013     

合并主动脉瓣反流大动脉炎患者的超声心动图特征

研究目的：在大动脉炎（Takayasu arteritis, TA）患者中,主动脉瓣反流（aortic regurgitation, AR）被认为是一种严重的并发症,其预后通常不佳。本研究的主要目标是探讨TA患者中AR的特征和潜在危险因素。 方法：本研究纳入了2020年12月至2022年8月于复旦大学中山医院住院的TA患者196例,根据有无合并AR分为AR组（n=67）和非AR组(n=129)。回顾性收集患者人口统计学信息、临床数据以及实验室检查结果。此外,使用超声心动图来测量心脏参数,包括升主动脉壁的厚度和主动脉瓣叶的厚度。采用多因素Logistic回归分析与AR发生的危险因素;使用Pearson相关系数来探究主动脉参数与缩流颈宽度（vena contracta width, VCW）之间的关系。 结果：在AR组中,心肌肌钙蛋白T（cardiac troponin T, cTnT）和N-末端前脑钠肽（N-terminal pro-brain natriuretic peptide, NT-proBNP）水平显著高于非AR组（均P<0.001）。与非AR组相比,AR组的主动脉窦部和升主动脉显著增宽（SoVD 33.8±4.5 mm vs. 29.9±3.1 mm, P=0.001; AAoD 37.7±6.1 mm vs. 30.1±4.7 mm, P<0.001）;同时,AR组的升主动脉壁和主动脉瓣叶显著增厚（升主动脉壁厚度 3.7±1.5 mm vs. 2.4±0.6 mm, P<0.001; 主动脉瓣叶厚度 2.8±0.9 mm vs. 1.8±0.3 mm, P<0.001）。多变量 logistic 回归分析的结果表明, SoVD、AAoD和主动脉瓣叶厚度是TA患者中AR的独立危险因素（P<0.05）。此外,AR的缩流颈宽度（vena contracta width, VCW）与SoVD、AAoD、升主动脉壁厚度和主动脉瓣叶厚度之间存在正相关关系（P<0.05）。 结论：主动脉窦部和升主动脉的扩张以及主动脉瓣叶的增厚,是与TA患者发生AR密切相关的危险因素。随着AR的进展,主动脉窦和升主动脉持续扩张,同时,主动脉瓣叶和升主动脉管壁不断增厚。定期进行超声心动图检查为检测这些与 AR 相关的危险因素提供了宝贵的手段,从而有助于制定明智的治疗决策,并提高 TA 患者的整体预后。     

Aortic dissection: A "humerus" case.

Aortic dissection usually presents with acute onset of severe chest pain. Classically there is a pressure differential between the 2 arms and widening of the mediastinum. Echocardiography is considered the investigation of choice in many institutions. A case is presented in which the presentation and clinical signs are classical for dissection. Transthoracic echocardiography demonstrated "enlargement" of the descending aorta and a "flap." A surprise diagnosis was made by transesophageal echocardiography. Other vascular structures in the para-aortic regions should be considered when the diagnosis of aortic dissection is entertained.     

Localized Aortic Dissection: Unusual Features by Transesophageal Echocardiography

Transesophageal echocardiography relies on the presence of an undulating intimal flap for the diagnosis of aortic dissection. Furthermore, to distinguish true dissection from echo artifacts, the flap has to be identified in more than one view, and it must have a motion independent of the aortic wall. We describe the transesophageal echocardiography appearance of a localized aortic dissection with atypical features for an intimal flap. Awareness of this unusual echocardiographic appearance of an intimal flap will avoid misdiagnosis of the potentially serious acute aortic dissection.     

Prise en charge précoce des insuffisances aortique et mitrale aigu?s en réanimation

Acute pulmonary edema is the most frequent presentation of aortic (AR) and mitral (MR) regurgitation in the intensive care unit (ICU). The etiologic diagnosis is performed using transthoracic echocardiography and mainly transesophageal echocardiography (TEE). The aim of the medical management in ICU is to stabilize the hemodynamic status of the patient before the surgical treatment, in the absence of major comorbidities. Timing of surgery depends on the response to the optimal medical treatment. It consists in a valve replacement with a bioprosthesis or a mechanical prosthesis or in a mitral valve repair. Acute type A aortic dissection is one of the etiologies of acute AR. Rupture of the ascending aorta is at the first line and severely impairs the final outcome. In the situation of an ischemic MR, management also includes myocardial revascularization. Infective endocarditis (IE) is responsible of the majority of the AR and MR in the ICU. TEE for the diagnosis is mandatory. Antibiotics represent the first line of the optimal medical treatment. Urgent valve surgery is indicated when regurgitation leads to acute heart failure. Early surgical treatment decreases the risk of embolic events, local extension and improves survival rate. Only hemorrhagic brain stroke could postpone surgery due to the risk of intra-cerebral bleeding induced by extracorporeal circulation. Prognosis of AR and MR is worse when caused by IE, and even more severe in case of IE on a prosthetic valve. A multidisciplinary team approach should improve the survival rate in ICU patients admitted with AR and MR-related morbidities.     

Using transesophageal echocardiography to manage critically ill patients. What role in hemodynamic instability, MI, embolic disease, trauma?

When transthoracic echocardiographic images are suboptimal, transesophageal echocardiography offers a new window for visualization of the heart and thoracic aorta. It can be performed at bedside in 15 to 20 minutes. Complications (emesis, hypoxemia, hypotension) are rare and easily reversed or averted by administration of naloxone or flumazenil. Indications include evaluation of hemodynamic instability, ventricular function, mitral regurgitation, ventricular septal defects, aneurysm, endocarditis, intracardiac sources of embolus, valve pathology, aortic dissection, intra-aortic debris, and trauma. Results can be analyzed immediately and used to guide further evaluation, medical therapy, or surgery.     

先天性二叶主动脉瓣畸形的超声诊断价值

目的分析先天性二叶主动脉瓣畸形(BAVD)的多普勒超声表现,以提高对该病的认识.方法采用Acuson 128xp10及Sequoia256彩超仪,通过经胸超声(TTE)及经食道超声(TEE)检测44例(BAVD)患者的主动脉瓣表现、并发症.结果BAVD在大动脉短轴切面上为两个瓣膜及两个瓣膜联合点,舒张期呈单一关闭线,75%患者有不同程度瓣膜受损.主动脉瓣狭窄(AS)占34%,主动脉瓣关闭不全(AR)占68%,升主动脉扩张占30%;合并主动脉瓣赘生物5例,伴二尖瓣病变5例,房间隔缺及膜周部室缺各1例.结论BAVD可出现不同程度的AS及AR和由此所致的各种血流动力学异常,可伴多种先天及后天性心血管异常.多谱勒超声是诊断BAVD及其并发症的最佳方法.     

经心尖途径经导管主动脉瓣置换术救治单纯性主动脉瓣重度反流1例

目的 探讨经心尖途径经导管主动脉瓣置换术治疗单纯性主动脉瓣关闭不全的可行性.方法 回顾性分析2016年9月8日浙江大学医学院附属第二医院心脏中心开展的浙江省首例经心尖途径经导管主动脉瓣置换术的术前评估、术中操作以及患者术后情况.结果 患者严格进行术前评估,术中行全身麻醉、气管插管,透视下定位后第五肋间小切口进胸,打开心包,选择心尖裸区预置荷包,穿刺后导入超滑泥鳅导丝跨过主动脉瓣到达降主动脉,导入J-Valve输送系统逐步释放,经食道超声心动图评估主动脉瓣反流从术前的大量到瓣膜释放后无反流,撤出瓣膜输送系统,手术成功结束.术后患者症状明显缓解,出现Ⅰ度房室传导阻滞,未发生死亡、心肌梗死、心包填塞、动脉夹层等并发症.结论 经心尖途径经导管主动脉瓣置换术是安全可行的,患者的远期预后还有待进一步观察.