Coronary Cusp Research Articles

Silent severe aortic regurgitation due to blunt chest trauma: ignore it at your peril—a case report

Abstract Background Blunt chest trauma (BCT) presenting to the emergency department is common and may cause life-threatening cardiac complications. Whilst complications causing haemodynamic instability are generally detected promptly, others may present late with long-term consequences. We describe a rare, serious complication of BCT presenting five years after a road traffic accident (RTA). Case summary A 23-year-old man was incidentally found to have a murmur. Past history was notable only for BCT with rib fracture sustained in a RTA 5 years prior. Examination revealed a hyperdynamic pulse, loud decrescendo diastolic murmur, and Duroziez’s sign over the femoral arteries. Echocardiography showed severe valvular aortic regurgitation (AR) from a hole in the left coronary cusp and holodiastolic flow reversal in the descending aorta. The left ventricle (LV) showed marked dilatation in diastole, mild dilatation in systole, and preserved systolic function. The aorta was normal. Severe AR was attributed to his previous BCT, with AR causing subsequent LV dilatation. He underwent aortic valve replacement (AVR) with rapid recovery. He remains well, and his echo shows a well-functioning AVR with normalization of LV dimensions. Discussion Aortic regurgitation following BCT is rare but well-recognized, most often resulting from RTAs. Only a third of cases are diagnosed acutely. In others, lack of haemodynamic instability means that emergency echocardiography is not routinely performed, such that this may go unrecognized with long-term consequences. Clinicians should be aware of possible valve damage following BCT. Prompt echocardiography should be routinely performed for all BCT at initial presentation, even without haemodynamic instability.

Quadricuspid aortic valve and its rare association with left main obstruction: case report and literature review.

The quadricuspid aortic valve (QAV) is a rare congenital anomaly. We report a 51-year-old woman with QAV who experienced intermittent chest pain due to fibrotic tissue overgrowth from the small left coronary cusp, obstructing the left main coronary artery (LM). Angiography revealed a large "Vieussens' arterial ring," which acted as a collateral channel from the right coronary artery to the left coronary artery, preserving coronary blood flow and left ventricular function. Surgery successfully removed the tissue, maintaining both aortic valve function and coronary patency. This case highlights the need to consider QAV complications and use various imaging modalities for accurate diagnosis and treatment planning, including evaluating potential issues like aortic regurgitation and coronary anomalies.

Premature ventricular contraction arising from the left coronary sinus cusp: Which signal is the target of ablation?

We described a premature ventricular contraction arising from the left coronary sinus cusp, in which we discussed about the interpretations of the signals recorded there. Our case provided further insights into the interpretation of signals recorded at the coronary sinus cusp during premature ventricular contraction ablation.

Scattered finding of Acute Severe aortic regurgitation in a child with Ventricular septal defect: floating non coronary cusp due to rupture fibrous strands

A 14 months kid was admitted for routine ventricular septal defect (VSD) closure surgery due to severe pulmonary hypertension (PHT) but day before surgery developed acute severe aortic regurgitation (AR). Per-operative findings highly suggested that this AR due to ruptures fibrous strands of aortic valve. He had no cardiac catheterization before surgery, so its due to turbulent VSD jet affected noncoronary cusp free floating. Refixation with multiple interrupted sutures make near normal anatomy with trival AR at 6 months follow up Echocardiography. Bangladesh Heart Journal 2024; 39(2): 177-178

Can the QRS morphology of outflow tract ventricular arrhythmia change when right bundle branch block emerges during sinus rhythm?

QRS morphology can change during ventricular arrhythmias (VAs) with the appearance of bundle branch block (BBB). We retrospectively investigated 195 consecutive patients who underwent an initial ablation of VA. The study inclusion criteria were VAs that were successfully ablated in the outflow tract (OT) and in whom right bundle branch block (RBBB) was induced by catheter manipulation close to the His bundle area during sinus rhythm, before any radiofrequency application. We analyzed the QRS morphology of the VAs with and without RBBB during sinus beats. Twenty-four patients (age 59±17 years, female 14) developed RBBB at some point during their procedure. The successful ablation sites of the VAs were the right ventricular outflow tract (RVOT) in 12 patients, pulmonary artery in one, left coronary cusp in five, right coronary cusp in three, right-left cusp junction in two, and great cardiac vein in two. QRS-morphology change was observed in five (20%) cases. The successful ablation sites in that group were the left coronary cusp in three cases, right coronary cusp in one, and RVOT septum in one. The QRS duration of the VAs increased during RBBB. There are some cases of OT-VAs in which the QRS waveform changes with the appearance of catheter induced RBBB. We need to be aware that when QRS morphology changes during an OT-VA ablation, it does not necessarily mean that the origin or exit of the VA has changed.

Papillary Fibroelastoma of the Aortic Valve:Acute Coronary Syndrome Due to Dynamic Obstruction of the Right Coronary Artery Ostium.

A 59-year-old woman, who had a history of acute coronary syndrome (ACS) but without obstructive coronary lesions 2 years previously, presented with vertigo. MRI revealed a left cerebellar embolism. TEE detected a mobile aortic valve tumor, suggesting a papillary fibroelastoma (PFE). Reviewing previous echocardiograms, it was discovered that the tumor was present at the time of the ACS event. At surgery, the PFE was present on the right coronary cusp. When the aortic valve was opened, it was found that the tumor was obstructing the right coronary artery (RCA) ostium. ACS was probably caused by PFE's dynamic obstruction of the RCA ostium.

Multiple aortic valve papillary fibroelastomas causing recurrent cerebrovascular events

IntroductionPapillary fibroelastomas (PFE) are benign, rare primary cardiac tumors often discovered incidentally during cardiac imaging or as part of a workup for thromboembolic or obstructive events. We present a case of multiple PFE on the aortic valve's right coronary and non-coronary leaflets, presenting as recurrent cerebrovascular events managed by resection with valve preservation. Case SummaryA 53-year-old male presented with an acute right frontal cerebrovascular accident and a history of recurrent transient ischemic attacks. A transesophageal echocardiogram (TEE) revealed a 10 × 8 mm mass on the right coronary cusp of the aortic valve. Differential diagnosis included PFE versus thrombus. Following a neurology evaluation, the patient was anticoagulated and scheduled for urgent cardiac surgery. During surgery, an 8 × 7 mm mass was sharply excised from the right coronary leaflet's anterior surface. Further examination revealed additional masses: a 3 mm mass on the underside of the right coronary leaflet, a 2 mm mass on the non-coronary leaflet, and another 2 mm mass on its underside. All masses were excised, and pathology confirmed the diagnosis of PFE. The patient's post-operative course was unremarkable, and a pre-discharge transthoracic echocardiogram (TTE) demonstrated complete removal of the aortic valve masses with normal ventricular and aortic valve function. DiscussionPFE are rare benign cardiac tumors with a significant risk of thromboembolic or obstructive events, including stroke. Grossly, they are attached to the endocardium by a short fibrous pedicle with multiple papillary fronds resembling a sea anemone. More than 95 % originate from the left heart, most commonly affecting the aortic valve. Diagnosis is primarily through echocardiography, with TEE being more sensitive than TTE. Surgical excision is curative, offering an excellent long-term prognosis. ConclusionAll patients with suspected embolic cerebrovascular events should undergo echocardiographic evaluation to assess for potential cardiac etiologies. Surgical resection of PFE results in uniformly excellent clinical outcomes, with aortic valve preservation achievable in over 98 % of cases.

Surgical management of native aortic valve leaflet avulsion during TAVR

BackgroundTranscatheter aortic valve replacement (TAVR) has increased in utilization since its approval for management of aortic stenosis patients across all risk strata. We report a rare case of aortic valve leaflet avulsion after balloon expandable TAVR managed with urgent surgery.Case presentationA 78-year-old male underwent TAVR complicated by avulsion of the native aortic valve leaflet’s left coronary cusp. He was taken for urgent surgery for cusp resection to prevent thromboembolic complications.ConclusionsNative aortic valve leaflet avulsion should be suspected during TAVR in instances of extreme hemodynamic instability after balloon aortic valvuloplasty. As TAVR expands in lower risk patients, surgeons should have a low threshold to intervene surgically to treat native leaflet avulsion or other complications.

Electrophysiological and Clinical Characteristics of Premature Ventricular Contractions (PVCs) Originating From the Left Coronary Cusp (LCC) Versus Site 3 of the Right Ventricular Outflow Tract (RVOT)

Electrophysiological and Clinical Characteristics of Premature Ventricular Contractions (PVCs) Originating From the Left Coronary Cusp (LCC) Versus Site 3 of the Right Ventricular Outflow Tract (RVOT)

Clinical, Electrophysiological Characteristics and Long-Term Outcomes of Catheter Ablation of Premature Ventricular Contractions Originating From Left Coronary Cusp

Clinical, Electrophysiological Characteristics and Long-Term Outcomes of Catheter Ablation of Premature Ventricular Contractions Originating From Left Coronary Cusp

Acute occlusion of the left main coronary artery following impedance rise after high-frequency catheter ablation.

We present a case of catheter ablation of a premature ventricular complex complicated by left main injury. During ablation from the left coronary cusp, a sudden rise in impedance was followed by ST elevation on the ECG. Angioplasty and stenting were performed immediately; however, the stent subsequently developed repeated stenosis.

Inferior ST elevation myocardial infarction in a patient with anomalous origin of the left coronary artery from the right coronary cusp.

Inferior ST elevation myocardial infarction in a patient with anomalous origin of the left coronary artery from the right coronary cusp.

Patients with a Bicuspid Aortic Valve (BAV) Diagnosed with ECG-Gated Cardiac Multislice Computed Tomography-Analysis of the Reasons for Referral, Classification of Morphological Phenotypes, Co-Occurring Cardiovascular Abnormalities, and Coronary Artery Stenosis.

Background/Objectives: The aim of this study was to analyze a group of patients with a bicuspid aortic valve (BAV) examined with ECG-gated cardiac CT (ECG-CT), focusing on the assessment of the clinical reasons for cardiac CT, cardiovascular abnormalities coexisting with their BAV, and coronary artery stenosis. Methods: A detailed statistical analysis was conducted on 700 patients with a BAV from a group of 15,670 patients examined with ECG-CT. Results: The incidence of a BAV in ECG-CT was 4.6%. The most common reason for examination was suspicion of coronary heart disease-31.1%. Cardiovascular defects most frequently associated with a BAV were a VSD (4.3%) and coarctation of the aorta (3.6%), while among coronary anomalies, they were high-take-off coronary arteries (6.4%) and paracommissural orifice of coronary arteries (4.4%). The analysis of the coronary artery calcium index showed significantly lower values for type 2 BAV compared to other valve types (p < 0.001), with the lowest average age in this group of patients. Moreover, the presence of a raphe between the coronary and non-coronary cusps was associated with a higher rate of significant coronary stenosis compared to other types of BAVs (p < 0.001). Conclusions: The most common reason for referral for cardiac ECG-CT in the group ≤ 40-year-olds with a BAV was the suspicion of congenital cardiovascular defects, while in the group of over 40-year-olds, it was the suspicion of coronary artery disease. The incidence of cardiovascular abnormalities co-occurring with BAV and diagnosed with ECG-CT differs among specific patient subgroups. The presence of a raphe between the coronary and non-coronary cusps appears to be a potential risk factor for significant coronary stenosis in patients with BAVs.

Gerbode defect resulting from Group B Streptococcus infective endocarditis: a case report

BackgroundGerbode defect is an unusual abnormal communication between the left ventricle and the right atrium and is a serious complication of aortic infective endocarditis. Group B Streptococcus is an uncommon cause of infective endocarditis and has a markedly destructive effect on valvular tissue. Acute fistulation between the left ventricle and the right atrium associated with this form of infective endocarditis is a life-threatening, aggressive complication that often requires urgent surgical intervention. However, the identification of actual communication is often extremely difficult. Herein, we describe an unusual case of Gerbode defect resulting from Group B Streptococcus infective endocarditis and discuss the issues surrounding such a rare cardiac defect and such an infection.Case presentationA 60-year-old man with underlying uncontrolled diabetes mellitus underwent endoscopic retrograde biliary drainage for acute cholangitis. On the 10th postoperative day, the patient developed multiple acute cerebral embolisms. Transthoracic echocardiography demonstrated severe aortic regurgitation and a large mobile vegetation near the tricuspid annulus. No obvious fistula between the left ventricle and the right atrium could be demonstrated. The blood culture examination was positive for Group B Streptococcus. The patient was diagnosed with Group B Streptococcus infective endocarditis, and antibiotic therapy was initiated. Transesophageal echocardiogram performed after referral to our hospital confirmed detachment of the right coronary cusp of the aortic valve from the annulus and an abnormal cavity immediately below the right coronary cusp. Color Doppler imaging finally revealed systolic blood flows from the left ventricle into the right atrium through the cavity. Therefore, we diagnosed the patient with Gerbode defect resulting from Group B Streptococcus infective endocarditis. In addition to aortic valve replacement, defect closure and left ventricular outflow tract repair were successfully performed urgently for severely complicated and uncommon infective endocarditis. The patient was uneventfully discharged without any complications.ConclusionsWe reported successful surgical treatment of unusual active IE and Gerbode defect caused by GBS. Careful preoperative echocardiographic work-up is imperative for accurate early diagnosis and successful repair.

A case of aortico-left ventricular tunnel previously confused with right coronary cusp aneurysm

A case of aortico-left ventricular tunnel previously confused with right coronary cusp aneurysm

Anatomical Annulus Predictors of New Permanent Pacemaker Implantation Risk After Balloon-Expandable Transcatheter Aortic Valve Implantation

New-generation transcatheter-heart-valves (THV) have significantly improved technical success and procedural safety of transcatheter-aortic-valve-implantation (TAVI) procedures, but incidence of permanent pacemaker implantation (PPI) remains a concern.The study aimed to assess the role of anatomical annulus features in determining peri-procedural conduction disturbances leading to new-PPI following TAVI with the last generation Edwards Sapien balloon-expandable valves (BEV). In the context of a prospective single-center registry, we integrated clinical and procedural predictors of PPI with anatomical data derived from multi-slice-computed-tomography (MSCT). A total of 210 consecutive patients treated with balloon expandable Edwards THV were included in the study from 2015 to 2023. Technical success was achieved in 197 (93.8%) procedures, and 26 patients (12.4%) required new-PPI at 30-day follow-up (median time-to-implantation 3 days). At the univariable logistic-regression analysis, pre-procedural right bundle branch block (RBBB; OR:2.24 [95%CI:1.01-4.97], p=0.047), annulus eccentricity ≥0.25 (OR:5.43 [95%CI:2.21-13.36], p<0.001), calcium volume at annulus of the right coronary cusp (RCC) >48 mm3 (OR:2.60 [95%CI:1.13-5.96], p=0.024) and prosthesis implantation depth greater than membranous septum length (OR:2.17 [95%CI: 1.10-4.28], p=0.026) were associated with new-PPI risk. At multivariable analysis pre-procedural RBBB (OR:2.81 [95%CI:1.01-7.85], p=0.049), annulus eccentricity ≥0.25 (OR:4.14 [95%CI:1.85-9.27], p<0.001), and annulusRCC calcium >48 mm3 (OR:2.89 [95%CI:1.07-7.82], p=0.037) were confirmed as independent predictors of new-PPI. In conclusion, specific anatomical features of the aortic valve annulus might have an additive role in determining the occurrence of conduction disturbances in patients undergoing TAVI with BEV. This suggests the possibility to use the MSCT to improve the prediction of post-TAVI new-PPI risk.

Impact of commissural versus coronary alignment on risk of coronary obstruction following transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) with commissural alignment aims to limit the risk of coronary occlusion and maintain good coronary access. However, due to coronary origin eccentricity within the coronary cusp, coronary-commissural overlap (CCO) may still occur. TAVI using coronary alignment, rather than commissural alignment, may further improve coronary access. To compare rates of CCO after TAVI using commissural versus coronary alignment methodology. Cardiac CT scans from 102 patients with severe (tricuspid) aortic stenosis referred for TAVI were analysed. Native cusp asymmetry and coronary eccentricity were defined and used to simulate TAVI using commissural versus coronary alignment. Rates of optimal coronary alignment (< 10° from cusp centre) and severe misalignment (< 15° from coronary-commissural overlap) were compared. Additionally, the impact of valve misalignment during implantation was assessed. The native right coronary artery (RCA) origin was 15.8° (9.5 to 24°) closer to the right coronary cusp/non-coronary cusp (RCC-NCC) commissure than the centre of the right coronary cusp. The native left coronary artery (LCA) origin was 4.5° (0 to 11.5°) closer to the left coronary cusp/non-coronary cusp (LCC-NCC) commissure than the centre of the left coronary cusp (p < 0.01). Compared to commissural alignment, coronary alignment doubled the proportion of optimally-aligned RCAs (62/102 [60.8%] vs. 31/102 [30.4%]; p < 0.001), without a significant change in optimal LCA alignment (62/102 [60.8% vs. 74/102 [72.6%]; p = 0.07). There were no cases of severe misalignment with either strategy. Simulating 15° of valve misalignment resulted in severe RCA compromise risk in 7/102 (6.9%) of commissural alignment cases, compared to none using coronary alignment. Fluoroscopic projection was similar with both approaches. Coronary alignment resulted in a 2-fold increase of optimal TAVI positioning relative to the RCA ostium when compared to commissural alignment without impacting the LCA. Use of coronary alignment rather than commissural alignment may improve coronary access after TAVI and is less sensitive to valve rotational error, particularly for the right coronary artery.

Imaging-derived tissue visualization guides catheter ablation of premature ventricular contractions

Abstract Background The presence of myocardial scarring is associated with worse outcomes after catheter ablation of premature ventricular contractions (PVCs). Three-dimensional substrate characterization is emerging for peri-procedural ablation guidance, but its value for tissue visualization during PVC ablation is unknown. Purpose The aim of the present study was to assess the impact of imaging-derived tissue visualization on lesion planning, procedural and clinical outcomes of PVC ablation. Methods Thirteen consecutive patients (92.3% male, 62.2±12.4 years) undergoing unipolar (n=8) or bipolar (n=5) PVC catheter ablation with integrated three-dimensional imaging from multidetector computed tomography or cardiac magnetic resonance imaging were included. All patients presented with assumed myocardial scarring due to an underlying cardiomyopathy and/or after previous ablation. Results Among all patients (30.8% (peri-)myocarditis, 20.0% ischemic, 15.4% dilated cardiomyopathy, 15.4% idiopathic, 7.7% nonischemic, 7.7% congenital heart disease) undergoing ablation of 20 PVC morphologies (median 1 (IQR 1-2) per patient; 75.0% non-outflow tract; 70.0% left-sided), myocardial scarring was present in 11/13 (84.6%). Wall thinning &amp;lt;5 mm covering an area of 36.1±17.8 cm² contained the PVC origin in 4/13 (30.8%) patients and was safely targeted with radiofrequency lesions with up to 45 W (maximum power: median 32 W (IQR 30-35)) (Figure 1). Imaging-guided bipolar ablation was performed in 5/8 (62.5%) patients with previously therapy-refractory PVCs including foci at the left ventricular summit and the right ventricular outflow tract each in 2 and the left coronary cusp in one patient (Figure 2). PVCs were efficiently suppressed with less radiofrequency lesions (5.4±3.8 vs. 55.8±36.9; p=0.0160) with shorter duration (4.1±3.2 min vs. 23.3±13.5 min; p=0.0152) compared to prior unipolar ablation. Bipolar lesions resulted in a higher impedance (158 Ω (IQR 101-174) vs. 106 Ω (IQR 99-124); p=0.0025), while requiring a lower temperature (36 °C (IQR 35-38) vs. 39 °C (IQR 36-43); p=0.0001) and less power (26 W (IQR 20-30) vs. 30 W (IQR 25-31); p=0.0376). Complete suppression of the clinical PVC was reached in all 13 patients. During a follow-up of 396.8±299.7 days, PVC burden decreased from 20.1±14.3% to 1.7±1.6% (p=0.0172). Conclusions Imaging-derived tissue visualization enables determination of myocardial wall thinning &amp;lt;5 mm as a substrate for recurrent PVCs, which can be safely targeted. Three-dimensional imaging efficiently guides high power lesion application and bipolar ablation of PVCs at anatomically challenging foci.Anatomically challenging fociImaging-guided bipolar ablation

CARDIOVASCULAR INVOLVEMENT IN SYSTEMIC LUPUS ERYTHEMATOSUS

Abstract Background Cardiovascular involvement is frequent in systemic lupus erythematosus (SLE). Aortic insufficiency is a common valvular abnormality seen in patients with systemic lupus erythematosus (SLE), it may be caused by a primary valve pathology or by an aortitis One of the cardiac manifestations associated with SLE and antiphospholipid syndrome (APLS) is Libman–Sacks endocarditis, also known as non–bacterial thrombotic endocarditis Although rare, there are reported cases of lupus aortitis which has also been associated with dissection, aneurysm and thrombus. Case Report We present a case of a 40 –years–old lady with lupus glomerulonephritis requiring immunosuppression and dialysis, who presented to the emergency department with fever and dyspnea. She was first treated with dialysis. Blood cultures drawn from central venous catheter peripheral were positive for staphylococcus epidermidis, the cultures from peripheral blood was negative instead.Transthoracic and transesophageal Echocardiography showed severe aortic regurgitation (not present three month earlier) with doubt valvular vegetations and with a focal enlargement of the aortic root (figure 1, 2).The patient met one major criterion (blood culture) and two minor criteria (high risk and fever), implying possible infective endocarditis. The patient was then started on intravenous antibiotics (vancomycin) and immunosuppression was reduced. Given the hemodynamic instability due to the severe aortic insufficiency, an Heart CT scan was performed to planned the surgical intervention. The CT scan confirmed the presence of small, multiple vegetation attached to the aortic leaflet and an aortic dissection on the right coronary cusp (figure 3). She proceeded to urgent surgery with aortic valve and aortic root replacement, the histology revealed evidence of Libman–Sacks endocarditis and aortitis. Discussion Our patient showed two different cardiovascular complications of SLE: the more frequent Libman –Sack endocarditis and the rare lupus aortitis associated to aortic dissection.The patient had risk factors for infective endocarditis and she did fulfil the modified Duke’s criteria for infective endocarditis and was treated with antibiotics and with a reduction of immunosuppression therapy. In fact, it can be difficult to distinguish between infective endocarditis and Libman–Sacks endocarditis especially in the setting of risk factors for both. Antibiotics and immunosuppressants should be used both.

A Case of Ross Procedure for Aortic Regurgitation due to Prolapse of a Right Coronary Cusp Caused by Natural Closure of Ventricular Septal Defect

A Case of Ross Procedure for Aortic Regurgitation due to Prolapse of a Right Coronary Cusp Caused by Natural Closure of Ventricular Septal Defect