Acute Severe Aortic Regurgitation Research Articles

TABERNACL: Temporary Hemodynamic Stabilization In Vivo.

Acute aortic regurgitation is life-threatening with few nonsurgical options for immediate stabilization. We propose Trans-Aortic Balloon to Ease Regurgitation Applying Counter-Pulsation (TABERNACL), a simple, on-table temporary valve using commercially available equipment to temporize acute severe aortic regurgitation. We hypothesize that an appropriately sized commercial balloon dilatation catheter-straddling the aortic annulus and connected to a counterpulsation console-can serve as a temporizing valve to restore hemodynamic stability in acute aortic regurgitation. We performed benchtop testing of valvuloplasty, angioplasty, and sizing balloons as counterpulsation balloons. TABERNACL was assessed in vivo in a porcine model of acute aortic regurgitation (n=8). We also tested a static undersized, continuously inflated transvalvular balloon as a spacer intended physically to obstruct the regurgitant orifice. Benchtop testing identified that Tyshak II and PTS sizing (NuMed Braun) balloon catheters performed adequately as temporary valves (ie, complete inflation and deflation with each cycle) and resisted fatigue, in contrast to others. When TABERNACL was used in the acute severe regurgitation animals, there was immediate hemodynamic improvement, with a significant 35% increase in diastolic aortic pressure by 16 mm Hg ([95% CI, 7-25] P=0.0056), 34% reduction in left ventricular end-diastolic pressure by -7 mm Hg ([95% CI, -10 to -5] P=0.0006), improvement in the aortic diastolic index by 0.28 ([95% CI, 0.18-0.39] P=0.0009), and reversal of electrocardiographic myocardial ischemia. As an alternative, static balloon inflation across the aortic valve stabilized regurgitation hemodynamics at the expense of a new aortic gradient and caused excessive ectopy from balloon movement in the left ventricular outflow tract. TABERNACL improves hemodynamics and reduces coronary ischemia by electrocardiography in animals with acute severe aortic regurgitation. TABERNACL valves obstruct the diastolic regurgitant orifice without systolic obstruction. This may prove a lifesaving bridge to definitive valve replacement therapy.

Factors Associated with Newly Developed Postoperative Neurological Complications in Patients with Emergency Surgery for Acute Type A Aortic Dissection.

Background and Objectives: Postoperative neurological complications (NCs) are an important cause of mortality in patients with acute type A aortic dissection (ATAAD). The aim of the study was to determine the association between intraoperative risk factors and newly developed postoperative NCs in patients after emergency surgery for ATAAD. Materials and Methods: A total of 203 patients requiring emergency surgery were included in the study. Patients with preoperative neurological dysfunction, deceased on the operating table or within the first 48 h after intensive care admission, with uncertain postoperative neurologic status or with incomplete records were excluded. Results: Mean age was 57.61 ± 12.27 years. Hyperlipidemia was the most frequent comorbidity (69%). A bicuspid aortic valve was present in 12.8% of cases, severe acute aortic regurgitation was present in 29.1% of patients, and cardiac tamponade was present in 27.1% of cases. The innominate artery was the most frequently dissected supra-aortic artery in 27.1% of cases. In 65% of cases, the primary entry tear was at the level of the ascending aorta. The incidence of newly developed postoperative NCs was 39.4%. The most common surgical technique performed was supra-coronary ascending aorta and hemiarch replacement, in 53.2% of patients. Using logistic regression, cardiopulmonary bypass time (OR = 1.01; 95% CI = 1.01-1.02; p < 0.001), aortic cross-clamp time over 3 h (OR = 2.71, 95% CI = 1.43-5.14, p = 0.002) and cerebral perfusion time (OR = 1.02; 95% CI = 1.002-1.03; p = 0.027) were independently associated with newly developed postoperative NCs. Conclusions: Based on the results of the study, all efforts should be made to reduce operative times. Using a simple surgical technique, like the supra-coronary ascending aorta and hemiarch technique, whenever possible, and using a simpler technique for cerebral perfusion like unilateral cerebral perfusion via the right axillary artery, could reduce operating times.

Establishing a Novel Diagnostic Framework Using Handheld Point-of-Care Focused-Echocardiography (HoPE) for Acute Left-Sided Cardiac Valve Emergencies: A Bayesian Approach for Emergency Physicians in Resource-Limited Settings.

Acute severe cardiac valve emergencies, such as acute severe mitral regurgitation (AMR) and acute severe aortic regurgitation (AAR), present significant challenges in terms of diagnosis and management. Handheld point-of-care ultrasound devices have emerged as potentially pivotal tools in ensuring the prompt and accurate diagnosis of these left-sided valve emergencies by emergency physicians, particularly in resource-limited settings. Despite the increased utilisation of point-of-care ultrasound by emergency physicians for the management of patients in states of acute cardiorespiratory failure, current diagnostic protocols cannot perform sufficient quantitative assessments of the left-sided cardiac valves. This review elucidates and evaluates the diagnostic utility of handheld point-of-care focused-echocardiography (HoPE) in native AMR and AAR by reviewing the relevant literature and the use of clinical case examples from the Emergency Department at Port Shepstone Regional Hospital (PSRH-ED)-a rural, resource-limited hospital located in KwaZulu-Natal, South Africa. Combining the findings of the review and clinical case illustrations, this review proceeds to synthesise a novel, Bayesian-inspired, iterative diagnostic framework that integrates HoPE into the evaluation of patients with acute cardiorespiratory failure and suspected severe left-sided valve lesions.

P6: Mechanical Circulatory Support for Acute Severe Aortic Regurgitation and Cardiogenic Shock

Background: We describe a case of cardiogenic and septic shock complicated by acute severe aortic regurgitation (AR) temporized by left-atrial-venoarterial (LA-VA) ECMO. Patient Presentation & Results: A 42-year-old female with end stage renal disease, type 2 diabetes, and osteomyelitis of the right foot on outpatient intravenous antibiotics presented with fevers. On initial evaluation, transthoracic echocardiogram (TTE) demonstrated normal left ventricular (LV) function with no valvular abnormalities and methicillin resistant staphylococcus aureus was identified in blood cultures. Despite several days of antibiotic treatment, the patient decompensated requiring intubation and vasopressors. Vitals were notable for a blood pressure of 80/10 mmHg. A repeat TTE demonstrated severe AR with leaflet perforation consistent with endocarditis. The patient suffered cardiac arrest and after return of spontaneous circulation, she was taken to the catheterization laboratory for mechanical circulatory support. Via the right femoral vein, initial transeptal puncture revealed a LA pressure of 35mmHg with V waves to 45mmHg. A 21Fr transeptal drainage cannula was placed in the LA with a 17Fr return cannula in the left common femoral artery for extracorporeal support with a Tandem Heart (Livanova) system. Right heart catheterization on 5Lpm of support along with epinephrine, levophed, dopamine and vasopressin were as follows: RA 13mmHg, PA 50/22 mmHg (mean 35mmHg, PA sat 53.5%) and CO/CI of 4.49/2.27 L/min/m2. Overnight the transeptal cannula was dislodged and an oxygenator was rapidly spliced converting the system to VA ECMO. On this configuration she underwent bedside guillotine amputation of the right foot and was then taken back to the catheterization laboratory where a second drainage cannula was placed into the LA, this time from the left femoral vein. A Y-connector was used to allow simultaneous inflow from both the displaced right atrial cannula (which was partially pulled into the IVC) and the new LA cannula into the pump (Picture 1). The patient underwent successful surgical aortic valve replacement (SAVR) with a 23mm Edwards Inspirus bioprosthesis. She was successfully weaned off circulatory support and ultimately discharged. Conclusion: Severe AR has been known to be a major contraindication for VA ECMO. In addition to hemodynamic instability and rapidly rising LA pressures with subsequent pulmonary edema, a noncompetent aortic valve makes MCS a unique challenge in cases of acute severe AR. In our case, normal LV function and unloading of the LA allowed for appropriate native LV output despite increased afterload from femoral artery return in the setting of severe AR. LA-VA ECMO created a window of hemodynamic stability to allow for amputation of an infected foot and successful SAVR.

Pneumococcal Endocarditis, Rare but Not Forgotten

Pneumococcal endocarditis incidence has significantly decreased since the advent of antibiotics but remains a significant cause of mortality and morbidity in high-risk groups, such as those with heart disease, chronic lung and liver disease, smoking, diabetes mellitus, and immunosuppression. We present a unique case of pneumococcal endocarditis with no clinical stigmata of infective endocarditis that manifested with acute hypoxic respiratory failure and severe aortic regurgitation. A large vegetation on the aortic valve was noted during surgery, with negative blood cultures and aortic valve tissue cultures but positive Streptococcus pneumoniae urinary antigen and polymerase chain reaction (PCR) test on the aortic valve.

Subendocardial Ischemia Caused by Acute Severe Aortic Regurgitation Due to Aortic Root Dissection: A Case Report and Literature Review.

Electrocardiogram (ECG) findings showing ST-segment depression in a wide range of leads and ST-segment elevation in aVR are found in patients with acute coronary syndrome with multivessel coronary lesions and left main trunk lesions. A 64-year-old man with a history of eosinophilic granulomatosis presented with chest pain and dyspnea. Although an ECG showed the above findings, he was diagnosed with acute severe aortic regurgitation (AR) complicating aortic root dissection and successfully underwent urgent Bentall operation. These ECG findings indicated that acute severe AR caused subendocardial ischemia.

1313 Unusual Supraannular Aortic Root Intimal Tear in a Patient with Severe Aortic Regurgitation

Abstract We present an extremely rare case of occult supraannular aortic root intimal tear in a patient presenting with acute severe aortic regurgitation (AR) and a previously undiagnosed bicuspid aortic valve. A 41-year-old Africo-Carribean female presented to the emergency department with acute pulmonary oedema and increasing dyspnea on exertion. She had been treated empirically with antibiotics for a chest infection. Initial concerns were either aortic dissection or infective endocarditis. Transthoracic echocardiography (TTE) demonstrated a normal size left ventricle with hyperdynamic systolic function and severe AR. The patient was transferred to a tertiary cardiothoracic surgical centre for urgent surgical treatment in view of haemodynamic instability and acute AR. A gated computed tomography aortogram identified pulmonary oedema with an asymmetrically dilated aortic root (maximal diameter 45 mm). Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and prompted Bentall procedure with mechanical aortic valve. After median sternotomy and initiation of cardiopulmonary bypass, a supraannular aortic intimal tear starting from the right coronary cusp/noncoronary cusp commissure was found with no extension into the aorta. The aortic valve was bicuspid and severe AR not amenable to repair was found. Bentall procedure was performed using the 23/26mm Carbomedics Carbo Seal Valsalva composite graft (Sulzer Carbomedics Inc, Austin, TX, USA). The patient was discharged on the 7th postoperative day in sinus rhythm. At 30-day clinical follow-up she was symptom free with a satisfactory TTE.

Subtle aortic dissection in a patient with severe aortic regurgitation and undiagnosed bicuspid aortic valve: A case report with a literature review

A subtle aortic dissection can be challenging to detect despite the availability of multiple diagnostic modalities. Whilst rare, the inability to detect this variant of aortic dissection can lead to a dismal prognosis. We present an extremely rare case of a subtle aortic dissection with supra-annular aortic root intimal tear and acute severe aortic regurgitation in a patient with a bicuspid aortic valve. Case report and literature review conserning subtle aortic dissection is provided. Initial concerns were either aortic dissection or infective endocarditis. Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and a Bentall procedure with a mechanical aortic valve was performed. Our case along with the review of current literature emphasizes that current imaging techniques may be inadequate for diagnosis of this rare variant of aortic dissection.

An unfortunate case of acute aortic regurgitation: Isolated aortic valve prolapse following a motor vehicle accident

We present an unfortunate case of severe acute aortic regurgitation (AR) following a motor vehicle accident (MVA) linked to isolated aortic valve prolapse, with no evidence of aortic root disruption or other valvular pathology missed on initial presentation. A 55-year-old gentleman, with known hypertension, was brought into the emergency department following a MVA, where he sustained severe intra-thoracic injuries. A bedside transthoracic echocardiogram (TTE) revealed a trileaflet aortic valve with evidence of mal-coaptation and severe AR. A computed tomography angiography of the thorax, however, failed to demonstrate evidence of dissection along the aortic root or ascending aorta. Following successful weaning off ventilatory support, the patient was discharged, but he presented back within a week with worsening dyspnoea and palpitations. Examination and investigation supported a diagnosis of acute heart failure with evident severe AR on repeat TTE. Transoesophageal echocardiography was performed, revealing prolapsed right and non-coronary cusps which were not seen in previous studies but absent evidence of the aortic root, ascending and descending aorta dilatation or dissection. Valvular complications rarely occur following blunt chest wall trauma, often involving right-sided valves due to their proximity to the sternum. Although aortic valve disruption can occur following MVAs, it is often associated with trauma to the aorta. Based on our literature search, there have been only a handful of reported cases of severe acute AR due to isolated prolapse or ruptured aortic valves in the absence of aortic valve perforation, aortic root disruption or dissection and other valvular abnormalities following trauma.

Clinical and echocardiographic predictors of decompensation in acute severe aortic regurgitation due to infective endocarditis.

Patients with acute severe aortic regurgitation (AR) due to infective endocarditis can progress rapidly from the hemodynamically stable patient to pulmonary edema and cardiogenic shock. We sought to identify patients at risk of decompensation where emergent surgery should be undertaken. We identified 90 patients with acute severe AR from the echocardiography laboratory database. Baseline clinical, hemodynamic (heart rate (HR) and blood pressure (BP)), and echocardiographic data including mitral filling, premature mitral valve closure (PMVC), and diastolic mitral regurgitation (DMR) were identified. The primary endpoint was subsequent development of pulmonary edema or severe hemodynamic instability. Patients who met the primary endpoint had a higher HR (98.5bpm vs 80.5bpm), lower diastolic BP (54mmHg vs 61.5mmHg), higher mitral E-wave velocity (113cm/s vs 83cm/s), higher E/e' ratio (12.4 vs 8), higher proportion of DMR (27.8% vs 7.4%), and PMVC (25% vs 9.3%) than patients who did not meet the endpoint. The proportion of patients with the primary endpoint increased as HR increased ((≤81bpm) 3/30 (10%), (81-94bpm) 11/31 (35.5%), (≥94bpm) 22/29 (75.9%), P<.0001) and as the diastolic BP reduced ((≤54mmHg) 19/31 (61.3%), (54-63mmHg) 12/31 (38.7%), (≥63mmHg) 5/28 (17.9%), P=.003). Independent predictors were a higher HR (OR 1.08 (95% CI 1.04-1.13) P=.0003) and DMR (OR 4.71 (95% CI 1.23-18.09), P=.02). Decompensation in acute severe AR is common. Independent predictors of decompensation are increasing HR(≥94bpm) and the presence of DMR. Those with these adverse markers should be considered for emergent surgery.

TRANS-CATHETER AORTIC VALVE IMPLANTATION (TAVI)-A CASE SERIES AT AFIC/NIHD

Objective: To share our experience of percutaneous trans-catheter aortic valve implantation in patients with severe symptomatic aortic stenosis.&#x0D; Study Design: A retrospective cross sectional study.&#x0D; Place and Duration of Study: The study was conducted at Armed Forces Institute of Cardiology/National Institute of Heart Diseases (AFIC/NIHD) Rawalpindi, from Mar 2015 to Feb 2020.&#x0D; Methodology: Retrospective analysis of all consecutive patients who underwent percutaneous trans-catheter aortic valve implantation was done to assess its immediate, short and long term outcome and safety. Twenty patients have undergone trans-catheter aortic valve implantation since 2015 in the institute. Base line blood chemistry including creatinine clearance, ultra-sonography abdomen, carotid Doppler, chest X-ray, High-Resolution Computed Tomography chest was done in all cases as part of the protocol. Mean age of the patients was 73 ± 7.91. There were sixteen males (80.0%) and four females (20.0%). All patients under went procedure through transfemoral route. Valve structure and peripheral vasculature for suitability of the procedure was assessed by computerized coronary tomographic angiography with TAVI protocol. In eleven patients aortic valve was trileaflet (55.0%) and in remaining nine it was bicuspid (45.0%). Mean gradient across the valve pre-procedure was 56.37 ± 9.14. Thirteen patients (65.0%) presented with angina/dysnoea NYHA III, 6 patients with syncope (30.0%) and one (5.0%) had heart failure. Two patients had undergone previous coronary artery bypass surgery. Procedure was carried out under general anesthesia in all patients except one. Balloon expandable Edwards Sapienvalve was implanted in two patients and self-expandable Core Valve/Evolut R in eighteen patients.&#x0D; Results: Seventeen patients underwent the procedure successfully with reduction of the mean gradients immediately after valve implantation to less than 15 mmHg recorded in the cath labangiographically subsequently complemented by transthoracic echocardiography. There were 3 deaths during the index hospitalization. Two occurred in the catheterization laboratory, one death was due to development of severe acute aortic regurgitation and second was due to acute coronary obstruction. Third death occurred due to acute kidney injury after seven days. Five patients died in next three months during follow up. One patient required permanent pacemaker because of development of left bundle branch block and second degree atrio-ventricular block post procedure.&#x0D; Conclusion: Transcatheter aortic valve implantation in patients with severe symptomatic aortic stenosis is a very effective and procedurally safe option and reasonable alternative to surgical valve replacement in high operative risk individuals.

Abstract 12934: Valve, Ventricle, Vessel or Virus: Who is the Shocking Culprit?

Introduction: Determining the etiology of dyspnea in patients with structural heart disease can be challenging, especially in the current era with high prevalence of COVID-19. Our case highlights the importance of evaluating bioprosthetic valve function in the setting of a change in clinical status. Case: An 82 year old female with surgical coronary revascularization and bioprosthetic aortic valve replacement in 2003 presented with dyspnea. Her evaluation revealed hypoxemia, leukocytosis and a chest x-ray supportive of viral infection when the local prevalence of both COVID-19 and influenza were at their peak. She was admitted to the intensive care unit with impending respiratory failure most likely from an infectious etiology. Echocardiogram revealed an ejection fraction (EF) of 25% and severe prosthetic aortic regurgitation with a pressure half time of 117ms ( Figure ). Six months prior, she had normal EF and normal prosthetic valve function. Interestingly, she lacked a wide pulse pressure, murmur of aortic insufficiency, and other characteristic exam findings of valvular dysfunction. The patient rapidly deteriorated into cardiogenic shock. Following urgent evaluation for transcatheter aortic valve replacement, she had successful valve-in-valve deployment of a 23mm Edwards S3 Ultra valve. Her hemodynamic parameters improved immediately and she was weaned from inotropic support 1 day following valve replacement. Conclusions: Evaluation of prosthetic valve function is integral when a patient’s clinical condition changes. In our patient, depressed EF resulting in an elevated left ventricular end-diastolic pressure likely diminished the regurgitant fraction and the expected aortic insufficiency murmur. Periodic evaluation of prosthetic heart valve function is necessary, particularly when the patient’s clinical condition changes. Acute severe aortic regurgitation with cardiogenic shock is fatal without rapid evaluation and valve replacement.

Mechanisms, features, and significance of diastolic mitral regurgitation: a case series.

BackgroundDiastolic mitral regurgitation (DMR) is a type of functional mitral regurgitation. Its occurrence in the diastolic phase of cardiac cycle renders DMR an easily ignored entity. Confusing it with systolic mitral regurgitation occasionally happens. The reversal of left atrioventricular pressure gradient during diastole and the incomplete closure of mitral valve are the essential conditions for DMR. Diastolic mitral regurgitation develops under various situations, where the mechanisms of diastolic reversal of left atrioventricular pressure gradient differ.Case summaryPatient 1 was a 50-year-old man diagnosed with 2:1 second-degree atrioventricular block (AVB). Patient 2 was a 70-year-old man diagnosed with first-degree AVB. Patient 3 was a 66-year-old man diagnosed with atrial fibrillation with long intermission and occasional atrial flutter with unequal conduction. Patient 4 was a 54-year-old woman diagnosed with dilated cardiomyopathy with complete left bundle branch block. Patient 5 was a 36-year-old man diagnosed with severe acute aortic regurgitation secondary to subacute bacterial endocarditis.DiscussionAlthough the degree of DMR is relatively mild, its appearance generally prompts further clinical considerations. The appreciation of DMR has an incremental value for diagnosing and evaluating the underlying cardiovascular disease.

Peripheral venoarterial extracorporeal membrane oxygenation for periprocedural Cardiogenic shock during interventional cardiology.

Cardiogenic shock (CS) is uncommon in the cardiac catheterization laboratory (CCL) among patients undergoing coronary angiography. Periprocedural CS is more frequent in high-risk patients and in technically demanding procedures. To describe the clinical outcomes of patients who underwent peripheral venoarterial extracorporeal membrane oxygenation (pVA-ECMO) for CS associated with interventional cardiology procedures. Review of clinical records of seven patients treated between January 2014 and October 2018. pVA-ECMO was implanted within 6 hours of the interventional cardiology procedure. All patients had coronary artery disease and one of them also had symptomatic severe aortic stenosis. One patient entered the CCL in cardiac arrest. Percutaneous coronary intervention (PCI) was performed in all patients; four patients underwent an emergency procedure and five patients experienced PCI complications. One patient undergoing transcatheter aortic valve replacement suffered acute severe aortic regurgitation. An intra-aortic balloon pump was inserted at the CCL in five patients. Six patients experienced cardiac arrest. Mean SAVE score was -4.3 and baseline lactate 55 mg/dl. pVA-ECMO mean duration was 5 ± 4 days. Survival after both hospital discharge and 12 months of follow-up was 85.7% Regarding vascular access complications, we observed one access site hematoma and one episode of cannulation site bleeding requiring surgical repair. pVA-ECMO should be considered in patients with periprocedural CS as a bridge to recovery. Its use was associated with improved clinical outcomes in this series.

Valvular Disease Begets Valvular Disease

In acute severe aortic regurgitation, an inversion of pressure gradient from the left ventricle to the left atrium causes the classical sign of end-diastolic mitral regurgitation. Here we present a case of mid-diastolic mitral regurgitation in a 51-year-old man with severe aortic regurgitation secondary to infective endocarditis. (Level of Difficulty: Beginner.)

422 Transoesophageal Echocardiography in Diagnosing Acute Aortic Dissection not Evident on CT Aortogram

CT aortogram is considered the gold-standard for diagnosing acute aortic dissection, but false-negative studies can occur. A 43-year-old male presented with sharp central chest pain radiating to his neck with associated dyspnoea, a viral prodrome and low-grade temperature (37.4°C). There was no documented blood pressure differential or audible murmur, ECG was unremarkable, and troponin-T was mildly elevated (22ng/L). CT pulmonary angiogram showed no pulmonary embolism, and a transthoracic echocardiogram (TTE) with suboptimal image quality indicated normal left ventricular (LV) size and systolic function, normal aorta size, mild aortic regurgitation (AR) and a small pericardial effusion. He was treated for suspected pericarditis, however developed acute kidney injury and acute pulmonary oedema requiring admission for ten days. He re-presented three days later with worsening dyspnoea, and a repeat transthoracic echocardiogram showed severe LV dilatation, dilated aortic root (45mm) and severe AR. An ECG-gated CT aortogram showed no evidence of aortic dissection. A transoesophageal echocardiogram (TOE) was performed to exclude endocarditis, and showed a Type A aortic dissection, dilated ascending aorta (48mm) and severe AR. He urgently underwent successful mechanical Bentall’s repair. This is an atypical presentation of acute aortic dissection diagnosed two weeks after initial presentation, with the dissection flap clearly visualised on TOE but not evident on CT aortogram. In retrospect, M-mode on the initial TTE identified fluttering of the anterior mitral valve leaflet consistent with an Austin-Flint murmur, and pulsed-wave Doppler indicated elevated stroke volume consistent with acute severe AR which was underappreciated on colour-flow Doppler.

P249 Iatrogenic aortic cusp laceration causing severe acute traumatic aortic regurgitation secondary to complex percutaneous coronary intervention using rotablator;3DTEE-anatomic correlates

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 &amp; 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.

Infective endocarditis of a bicuspid aortic valve complicated by ventricular septal defect

We report the case of a 36 years-old male, who was admitted to the cardiology department for prolonged fever, NYHA II Dyspnea and asthenia. Clinical examination found a febrile patient (39.2 °C) with diffuse purpiric spots and a 4/6 diastolic murmur in the Aortic area. Blood tests revealed high C-reactive protein level (236 mg/L) and procalcitonin(4.6 mg/L), in addition to hyperneutrophilia (18000/mm3), Anemia of Inflammation (Hb= 7.1 g/dL) and thrombopenia (98000/mm3). Renal function was altered ( GFR(MDRD)= 37 mL/min), Urine tests found high proteinuria (3g/24h) and hematuria. Transthoracic Echocardiography (TEE) was performed and showed tickened Aortic Valves with two large vegetations on the ventricular side of the Aortic cuspis measering 22x16mm and 12x17mm respectively, associated to a severe acute aortic regurgitation and a suspected sievers type 1 Bicuspid Aortic Valve (BAV). Moreover, a restrictive Ventricular Septal Defect (VSD) of 5 mm was found, in addition to an important tricuspid insufficiency and a transvalvular gradient estimated to 57 mmHg. Repeated Blood cultures were sterile, thus, empirical antibiotherapy including Vancomycin and Gentamicin was initiated and the patient underwent surgery with Aortic Valve Replacement and Tricuspid annuloplasty. The Sievers I/LR BAV was confirmed in peroperative findings. Post-operative period was marked with a favorable evolution with apyrexia, inflammation markors normalization and no residual vegetation in the post-operative TTE. The patient was discharged from hospital as he was asymptomatic and was regularily followed-up.

Successful use of extracorporeal cardiopulmonary membrane oxygenation in acute severe aortic regurgitation with cardiovascular collapse

We report the case of a 55-year-old man who was transferred from an overseas institution with an initial impression of non-ST-elevation myocardial infarction (NSTEMI). Subsequent investigation found a severe aortic regurgitation (AR) complicated by acute ischemic hepatitis and acute renal injury, and the patient developed cardiopulmonary collapse with pulseless electrical activity perioperatively. Cardiopulmonary resuscitation was commenced immediately, venoarterial extracorporeal membrane oxygenation (ECMO) was immediately set up to bridge for emergency aortic-valve replacement surgery. The patient was subsequently weaned off ECMO and made a complete recovery. We demonstrate the successful use of ECMO for resuscitation in a patient with AR complicated by cardiovascular collapse.

MICROBIOLOGY OF ACUTE SEVERE AORTIC REGURGITATION COMPLICATING INFECTIVE ENDOCARDITIS

Acute severe aortic regurgitation (AAR) from infective endocarditis (IE) commonly presents with hemodynamic instability and urgent surgery is indicated. We sought to determine the clinical outcomes and microbiological profiles of IE complicated by AAR in a contemporary dataset. Consecutive patients