Cause Of Aortic Regurgitation Research Articles

Contemporary Valvular Mechanisms of Aortic Regurgitation in Tricuspid Aortic Valves: Importance in Repair Versus Replacement Strategy.

This study was performed to determine cusp causes of aortic regurgitation in patients with tricuspid aortic valves without significant aortic dilatation and define cusp pathologies amenable to surgical repair (aortic valve repair [AVr]) versus aortic valve replacement. We retrospectively reviewed surgical reports of consecutive adults with tricuspid aortic valves undergoing surgery for clinically significant aortic regurgitation within a prospective registry from January 2005 to September 2019. Valvular mechanisms were determined by systematic invivo intraoperative quantification methods. Of 516 patients, 287 (56%) underwent repair (AVr; mean±SD age, 59.9±12.4 years; 81% men) and 229 (44%) underwent replacement (aortic valve replacement; mean±SD age, 62.8±13.8 years [P=0.01 compared to AVr]; 67% men). A single valvular mechanism was present in 454 patients (88%), with cusp prolapse (46%), retraction (24%), and perforation (18%) being the most common. Prolapse involved the right cusp in 86% of cases and was more frequent in men (P<0.001). Two-dimensional transesophageal echocardiography accuracy for predicting mechanisms was 73% to 82% for the right cusp, 55% to 61% for the noncoronary cusp, and 0% for the left-coronary cusp. Cusp prolapse, younger age, and larger patient size were associated with successful AVr (all P<0.03), whereas retraction, perforation, older age, and concomitant mitral repair were associated with aortic valve replacement (all P<0.03). Right cusp prolapse is the most frequent single valvular mechanism in patients with tricuspid aortic valve aortic regurgitation, followed by cusp retraction and perforation. The accuracy of 2-dimensional transesophageal echocardiography is limited for left and noncoronary cusp mechanistic assessment. Prolapse is associated with successful AVr, whereas retraction and perforation are associated with aortic valve replacement. With systematic intraoperative quantification methods and current surgical techniques, more than half of tricuspid aortic valve aortic regurgitation cases may be successfully repaired.

Massive Restrictive Aortic Regurgitation Caused by Aortic Chordae Tendineae Strands: Unusual Links

Determination of the etiology of a valvular heart disease is one of the major steps of every echocardiogram. Sometimes very unusual and rare etiologies can be found. In this article we report a case of very rare cause of aortic regurgitation, caused by the presence of aortic chordae tendineae strands leading to aortic cusps restriction in young asymptomatic athlete. In this case, we discuss two major problems. The first is the challenging diagnosis of this chordae tendineae strands, the second is the evaluation of an asymptomatic severe aortic regurgitation in a competitive athlete with an enlarged left ventricle.

Florida sleeve procedure for type II aortic regurgitation with aortic root enlargement: a case report

Abstract Background Florida sleeve procedure is an operative technique for aortic root reconstruction that offers advantages such as reduced bleeding risk, shorter operation time, and improved formation of the atrioventricular junction (AVJ) and sinotubular junction (STJ). In our department, we perform a Florida sleeve procedure for aortic regurgitation (AR) associated with aortic root enlargement of less than 40 mm in diameter of the Valsalva sinus. Here, we present a case of severe type II AR with aortic root enlargement where we successfully performed Florida sleeve procedure and augmented it with autologous pericardium. Case presentation A 62-year-old male patient was referred for cardiovascular surgery after a transthoracic echocardiogram indicated left ventricular enlargement and severe AR. Preoperative multidetector computed tomography (MDCT) revealed AVJ of 28.2 mm, Valsalva sinus of 38.4 mm, STJ of 36.1 mm, and ascending aorta of 40.1 mm, indicating enlargement from the aortic root to ascending aorta. Preoperative transesophageal echocardiography (TEE) revealed that the main cause of AR was suspected to be the right coronary cusp prolapse (RCC). Intraoperative findings showed that the tricuspid aortic valve had no limitation of motion, but the RCC was subjected to central bending and prolapsed. The leaflet bend was thickened and shortened causing AR (type II). The geometric height (gH) of RCC was short at 14 mm, while the other valve cusps were 20 mm. An augmentation of RCC was performed using autologous pericardium, followed by a Florida sleeve procedure performed using 26-mm Gelweave Valsalva™ grafts. The gH of RCC after augmentation was 23 mm, and the effective height was adjusted to 10 mm by central plication, showing no AR by TEE. Postoperative MDCT revealed AVJ of 22.2 mm, Valsalva sinus of 30.9 mm, and STJ of 21.9 mm. Therefore, the Florida sleeve procedure provided a reduction that preserved the geometry of the aortic root, including AVJ and STJ, as intended. Conclusions Florida sleeve procedure is a reliable and simple method for ensuring uniform aortic root geometry. A favorable outcome was obtained using the Florida sleeve procedure and augmentation with autologous pericardium in a patient with type II AR and aortic root enlargement.

Iatrogenic injury of aortic valve leaflet during mitral valve replacement: A transesophageal echocardiographic finding

Iatrogenic aortic valve injury during non-aortic cardiac surgery is an infrequent complication. Iatrogenic aortic regurgitation (AR) has been reported after mitral valve repair, aortic valve repair, septal myomectomy, closure of the ventricular septal defect, and atrial septal defect repair. Various causes have been reported for AR after non-aortic cardiac surgery. Perforation of the aortic valve leaflet is a common cause of AR. Other causes of AR are leaflet tension and leaflet retraction due to inadvertent suture placement. A few previous case reports have presented severe AR as a complication of iatrogenic involvement of aortic valve leaflet during MV surgery. We report a case of severe AR and severe aortic stenosis occurring immediately after mitral valve replacement. This was diagnosed intraoperatively by Transesophageal echocardiography (TEE) and aortic valve replacement was done.

Prolapse repair for aortic regurgitation in tricuspid aortic valves

ObjectiveCusp prolapse is an important cause of aortic regurgitation (AR) in tricuspid aortic valves (TAVs) and can be caused by myxomatous degeneration or cusp fenestration. Long-term data for prolapse repair in TAVs are scarce. We analyzed the results of aortic valve repair in patients with TAV morphology and AR caused by prolapse and compared the results for cusp fenestration and myxomatous degeneration. MethodsBetween October 2000 and December 2020, 237 patients (221 male; 15-83 years) underwent TAV repair for cusp prolapse. Prolapse was associated with fenestrations in 94 (group I) and myxomatous degeneration in 143 patients (group II). Fenestrations were closed using a pericardial patch (n = 75) or suture (n = 19). In myxomatous degeneration, prolapse was corrected by free margin plication (n = 132) or triangular resection (n = 11). Follow-up was 97% complete (cumulatively 1531, mean 6.5, median 5.8 years). Cardiac comorbidities were present in 111 patients (46.8%), and more frequent in group II (P = .003). ResultsTen-year survival was better in group I (I: 84.5%; II: 72.4%; P = .037), and patients without cardiac comorbidities (89.2% vs 67.0%; P = .002). Ten-year freedom from reoperation (P = .778), moderate or greater AR (P = .070), and valve-related complications (P = .977) were similar in both groups. AR at discharge was the only significant predictor for reoperation (P = .042). The type of annuloplasty did not affect repair durability. ConclusionsRepair of cusp prolapse in TAVs with preserved root dimensions can be performed with acceptable durability, even in the presence of fenestrations.

An Unusual Cause of Aortic Regurgitation in a Patient With Bicuspid Aortic Valve

Aortic fibrous strands are considered residual tissue from aortic valve development. Rupture of these strands is an important albeit uncommon cause of aortic regurgitation (AR). The authors describe a 67-year-old man who was admitted to the authors' hospital with sudden onset shortness of breath and diagnosed with severe AR. The patient was scheduled for Bentall surgery. The transesophageal echocardiogram (TEE) found multiple fibrous strands that were present in multiple locations of the aortic valve, some of which were ruptured. Ruptured fibrous strands are in the differential diagnosis in patients presenting with acute AR without a more conventional explanation, and TEE is instrumental in securing the diagnosis.

АОРТОАРТЕРІЇТ І ТЯЖКА АОРТАЛЬНА НЕДОСТАТНІСТЬ У ПАЦІЄНТКИ ПІСЛЯ COVID-19

Aortoarteritis is a rare cause of the aortic insuffi ciency, but it should be considered among the other causes of aortic regurgitation. A number of cases of autoimmune aortoarteritis have been reported during the COVID-19 pandemic. We present a case report of aortoarteritis with severe aortic insuffi ciency, which developed in a patient after a mild form of coronavirus infection and an episode of arthritis. Echocardiography revealed severe aortic regurgitation, dilatation of the thoracic aorta and thickening of the aortic walls. Ultrasonography showed thickening of the carotid arterial walls. Computed tomography confi rmed the diagnosis of aortoarteritis. Elevated C-reactive protein indicated an acute infl ammatory process. Aortoarteritis was treated with methylprednisolone with good clinical response. Possible causes of aortoarteritis are discussed: Takayasu arteritis, giant cell arteritis, ankylosing spondylitis and polychondritis. After exclusion of all possible causes, aortoarteritis in the patient was diagnosed as an autoimmune process caused by coronavirus infection. Cases of arteritis in patients related to COVID-19 are discussed. Multimodality diagnostics (echocardiography, contrast-enhanced computed tomography, ultrasonography of aortic branches) play a central role in detecting aortic lesions and evaluating the extent of the pathological process in aortitis. A laboratory workup is needed to identify the cause of the aortitis. The fi nal diagnosis should be made on the analysis of clinical manifestations, diagnostic and laboratory fi ndings.

A heart in a heart: a case report of spontaneous flail of bicuspid aortic valve

BackgroundAortic regurgitation is attributed to congenital and acquired abnormalities of the aortic valve or aortic valve supporting structures. The most common cause of aortic regurgitation is atherosclerotic degeneration of the valve, especially in the presence of a bicuspid aortic valve.Case summaryA 25-year-old Persian man with no past medical history, developed dyspnea since 1 week before his first visit to the physician. He was an active person up to this time, and had no history of trauma or chest pain. Transthoracic echocardiography showed severe aortic regurgitation in the context of flail bicuspid aortic valve, with no evidence of endocarditis. Laboratory tests including blood cultures were negative for infection. The patient underwent aortic valve replacement and the diagnosis was confirmed at time of surgery.ConclusionThis case represents noninfective and nontraumatic spontaneous flail of bicuspid aortic valve.

Elevated C-reactive protein is significantly associated with left ventricular dysfunction in patients with aortic regurgitation and concomitant collagen disease

BackgroundCollagen disease is an important cause of aortic regurgitation (AR). Although aortic valve surgery is recommended for patients with AR and depressed left ventricular (LV) function, there have been few reports about risk factors for LV dysfunction in patients with AR concomitant with collagen disease. Methods and resultsWe conducted this study at Kumamoto University Hospital in Japan. A total of 41 patients who had moderate to severe AR and concomitant collagen disease between January 2014 and December 2019 were enrolled. With regard to baseline characteristics, there were no significant differences in the type of collagen disease or El Khoury class between patients with preserved LV function and those with reduced LV function. B-type natriuretic peptide (375.2 [257.9–3852.6]pg/ml vs. 64.0 [33.3–133.6]pg/ml, p < 0.01), C-reactive protein (CRP) levels (2.00 [1.24–9.14]mg/dl vs. 0.19 [0.06–0.52]mg/dl, p < 0.01) and neutrophil-to-lymphocyte ratio (7.94 [3.30–9.98] vs. 3.94 [1.83–5.58], p < 0.05) were significantly higher, and hemoglobin level (10.7 ± 1.6 g/dl vs. 12.2 ± 1.8 g/dl, p < 0.05) was significantly lower in patients with reduced LV function than in those with preserved LV function. There were no significant differences in any variables associated with severity and features of AR. Multivariable logistic regression analysis showed that high CRP levels (≥1.0 mg/dl) were independently and significantly associated with LV dysfunction in patients with AR and collagen disease, even after adjusting for the severity of AR (odds ratio: 95.7; 95% confidence interval: 4.6–1990.4, p < 0.01). ConclusionsUncontrolled inflammation, represented as high CRP levels, is an important marker for LV dysfunction in patients with AR and collagen disease.

Abstract 15169: De Novo Variants of USP10 in Early Onset Bicuspid Aortic Valve Disease

Introduction: Bicuspid Aortic Valve (BAV), the most common congenital heart defect, is a major cause of aortic regurgitation or stenosis requiring valve replacement and thoracic aortic aneurysms predisposing to acute aortic dissections (TAD). The spectrum of BAV ranges from severe early onset valve and aortic complications to sporadic late onset disease. Hypothesis: Early onset BAV (EBAV) cases with valve or aortic complications that require intervention prior to age 30 are enriched for rare genetic variants that cause BAV and TAD. Methods: We performed whole exome sequencing of 147 EBAV cases in 141 families who were enrolled in the UTHealth Bicuspid Aortic Valve Research Registry. Candidate variants in the EBAV cohort (26% female, mean age 18, 44% with TAD) were compared to unselected controls from the Genome Aggregation Database (gnoMAD) and the Database of Genotypes and Phenotypes (dbGAP). We considered variants with minor allele frequencies (MAF) &lt; 1%, Combined Annotation Dependent Depletion (CADD) scores &gt; 25, and damaging (Polyphen-2) or deleterious (SIFT) functional prediction scores. Genomic copy number variants (CNVs) were detected using CoNIFER and prioritized when deletions involved genes with probability of loss intolerance (pLI) &gt; 0.9. Variants were validated using quantitative PCR or Sanger sequencing. Results: We identified 6 rare variants of USP10 in 6 EBAV families (4% of cohort): 4 CNVs (2 duplications and 2 deletions) that are rare in dbGAP controls (4 in 15,414) and 2 deleterious rare missense variants (MAF&lt;5x10 -5 in gnoMAD). Two of the 4 CNVs were de novo events in trios. In contrast, rare deleterious variants of the known causal BAV genes NOTCH1 (1), ROBO4 (1), GATA4 (1), GATA5 (1), and SMAD6 (4) were found in 7 total families. USP10 encodes a ubiquitin peptidase that is required for endothelial Notch signaling during vascular development. Conclusions: We identified rare and de novo variants of USP10 that implicate USP10 as a new candidate gene for BAV.

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

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&amp;lt;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&amp;lt;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

ATRAUMATIC AORTIC VALVE COMMISSURAL AVULSION CAUSING ACUTE SEVERE AORTIC REGURGITATION: CHALLENGES WITH NONINVASIVE IMAGING

Aortic valve commissural avulsion (CA) is a rare cause of aortic regurgitation (AR), usually related to infectious endocarditis, aortic dissection, or chest wall trauma. Spontaneous avulsion is seldom described. A 58 year-old man with history of polysubstance abuse presented to our emergency room

Aortic Regurgitation due to Commissural Dehiscence of the Aortic Valve

Commissural dehiscence of the aortic valve is a rare cause of aortic regurgitation. We report a 53-year-old male who had progressive aortic regurgitation and aortic root dilatation. A flap or intimal tear of the proximal aorta was absent with echocardiography and computed tomography. Transesophageal echocardiography revealed prolapse of the right and left coronary cusps with no intimal flap in the ascending aorta. During the operation, there was no dissection or intramural hematoma in the ascending aorta. However, there was dehiscence of the commissure between the right and left coronary cusps of the aortic valve. Aortic root and ascending aortic replacements were successfully performed. Commissural dehiscence of the aortic valve should be taken into account when prolapse of the aortic cusp is the cause of aortic regurgitation.

Aortic valve repair update.

The key for successful valve repair is full understanding of the regurgitant mechanism and sufficient evaluation of the valve. Currently, multidetector computed tomography has been introduced for evaluation. The aortic valve can be analyzed in details preoperatively. The main causes of aortic regurgitation (AR) in the adult population are degenerative leaflet change and annulus dilatation. Restoration to normal structure can be accomplished mainly by plication. Central leaflet plication near the Arantius nodule is a simple technique for redundant tissue. For leaflet deficiency, pericardial patch plasty may be an option. No universal technique exists for plication of the aortic annulus. The valve-sparing aortic root replacement firmly stabilizes the ventriculo-aortic junction (VAJ) and assures repair durability even in patients with mild to moderate root dilatation. Subcommissural annuloplasty (Cabrol stitch) does not seem sufficient for the prevention of VAJ dilatation. Circumferential annuloplasties may have a greater potential. However, convenient device for annular plication is still in development. The bicuspid aortic valve is a congenital heart valve lesion. A basic technique is free margin plication of the fused leaflet. Aortic root dilatation may contribute to AR severity. Valve-sparing aortic root replacement may improve repair durability. Considering the great advances in valve repair, young patients with AR should be informed that valve repair is a promising option for surgical treatment.

Técnicas de reparación valvular aórtica

Aortic valve repair has evolved dynamically in the past two decades, and has markedly benefitted from a better understanding of normal aortic root and valve geometry. Current research focuses on some special aspects, such as technique for cusp repair or replacement, stabilization of the basal ring, and ideal material for the repair. Cusp prolapse in bicuspid and tricuspid aortic valves is the most frequent cause of aortic regurgitation in industrialized countries. On the basis of recent literature, as well as on our own experience, several recommendations are suggested for the most appropriate surgical management of the patients with aortic regurgitation due to cusp pathology. Details are presented on the diagnosis and intraoperative systematic analysis to be followed, as well as the different surgical techniques to be employed. The results obtained in 1808 patients undergoing aortic valve repair in our institution are presented.

Aortic regurgitation associated with chronic bacterial endocarditis in one adult thoroughbred gelding

This article describes chronic bacterial endocarditis as the cause of aortic regurgitation in a 25-year-old Thoroughbred used for horseback riding. The horse presented signs of depression, exercise intolerance, and weight loss. A pandiastolic murmur was identified, but no other clinical signs of bacterial endocarditis were identified. Haematological, serum biochemical, and urine analyses did not show any particular abnormalities. Electrocardiography showed a physiological dysrhythmia that was not pertinent to this case. Echocardiography revealed left ventricle (LV) dilatation and a nodule in the left coronary cusp of the aortic valve associated with regurgitation. Based on the prevalence of aortic valve pathology in geriatric horses, a noninfectious condition with a myxomatous noninflammatory infiltrate was suspected; therefore, no special treatment was prescribed due to the absence of heart failure. Several months later, the animal was euthanised after experiencing a femur fracture. At necropsy, the horse showed an eccentric left ventricle hypertrophy and 2 nodules in the left coronary cusp of the aortic valve. Histological examination revealed the presence of bacteria, which led to the diagnosis of chronic bacterial endocarditis.

A quadricuspid aortic valve causing moderate aortic regurgitation

Quadricuspid aortic valve (QAV) is a rare cause of aortic regurgitation. Most cases are detected incidentally during echocardiography, angiography, autopsy or surgery. It may also be associated with other congenital anomalies of the heart. A 70 year-old man was admitted to our hospital with a five-month history of dyspnea. Echocardiographic examination showed a QAV leading to moderate aortic regurgitation, severe mitral regurgitation, left ventricular dysfunction and aortic root dilatation. Surgical treatment was considered, but the patient refused. We describe a case of QAV leading to aortic regurgitation.

Dehiscence of Freestyle aortic valve visualized by real-time three-dimensional transoesophageal echocardiography and dual-source computed tomography: a rare cause of aortic regurgitation

A 54-year-old man was admitted because of acute decompensated heart failure. Ten years ago, he underwent implantation of a 27 mm Freestyle aortic root stentless bioprosthesis (Medtronic Inc., Minneapolis, Minnesota) with a subcoronary technique for severe aortic regurgitation (AR) due to the bicuspid valve, combined with mitral valve repair for moderate mitral regurgitation (MR) due to anterior leaflet prolapse. …

Acute Aortic Regurgitation with Myocardial Infarction: An Important Clue for Aortic Dissection

BackgroundAortic dissection is an important cause of acute chest pain that should be rapidly diagnosed, as mortality increases with each hour this condition is left untreated. The diagnosis can be challenging, especially if concomitant myocardial infarction is present. Echocardiography is an important tool for the differential diagnosis. ObjectivesTo stress the importance of recognizing aortic regurgitation for the differentiation of myocardial infarction and aortic dissection. Case ReportAn 80-year-old woman was admitted to our hospital with chest pain that was diagnosed as inferior and lateral wall myocardial infarction based on electrocardiographic findings. The diagnosis was reevaluated when aortic regurgitation was detected on echocardiography. Closer inspection of the ascending aorta revealed a dissection flap as the cause of aortic regurgitation. ConclusionDetection of aortic regurgitation in a patient with myocardial infarction and normal valves should prompt the search for a possible aortic dissection, whether or not the dissection flap can be visualized.

Dynamic Aortic Pouch: A Rare Etiology of Aortic Regurgitation

The causes of aortic regurgitation (AR) include rheumatic heart disease, infective endocarditis, and various congenital and degenerative defects. We report an unusual case of AR in a 72-year-old man due to an aortic root pouch. The diagnosis AR was made by cardiac echocardiography, and the cause was revealed by cardiac catheterization and 64-slice cardiac computed tomography. During aortic valve replacement, a saccular pouch between the noncoronary cusp and the right coronary cusp of the aortic valve was noted.