Progressive worsening of aortic regurgitation due to detachment of the aortic valve commissure with multimodality imaging to elucidate pathogenesis: a case report

Shun Nishino; Masanori Nishimura; Yujiro Asada; Atsushi Yamashita; Yoshisato Shibata

doi:10.1093/ehjcr/ytae178

Progressive worsening of aortic regurgitation due to detachment of the aortic valve commissure with multimodality imaging to elucidate pathogenesis: a case report

Eur Heart J Case Rep. 2024 Apr 9;8(4):ytae178. doi: 10.1093/ehjcr/ytae178. eCollection 2024 Apr.

Authors

Shun Nishino¹, Masanori Nishimura², Yujiro Asada³, Atsushi Yamashita⁴, Yoshisato Shibata¹

Affiliations

¹ Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center, 1173 Arita, Miyazaki 880-2102, Japan.
² Department of Cardiothoracic Surgery, Miyazaki Medical Association Hospital Cardiovascular Center, Miyazaki, Japan.
³ Department of Pathology, Miyazaki Medical Association Hospital Cardiovascular Center, Miyazaki, Japan.
⁴ Department of Pathology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan.

Abstract

Background: Aortic regurgitation (AR) associated with detachment of the aortic valve commissure is extremely rare. We present a case of progressively worsening severe chronic AR due to detachment of the aortic valve commissure during hospitalization that was confirmed with multimodality imaging.

Case summary: A 50-year-old male with Marfan syndrome visited our hospital to receive treatment for cholelithiasis. Pre-operative examination revealed severe AR and aortic root aneurysm. Because the patient was asymptomatic, it was decided that cholecystectomy should be performed first. However, the patient's heart failure worsened acutely when his blood pressure increased just before induction of anaesthesia. The patient required intubation and management of heart failure. Five days later, the patient underwent cholecystectomy. He was treated for heart failure and underwent open heart surgery on the 35th hospital day. Intraoperative transoesophageal echocardiography revealed that his AR was caused by both enlargement of the aortic root and localized dissection of the aortic valve commissure, which was supported by intraoperative findings and histopathological evaluation. Aortic regurgitation was exacerbated by a new localized dissection, resulting in acute worsening of heart failure.

Discussion: Aortic valve commissure detachment can easily lead to sudden onset of severe AR, deteriorating haemodynamics, and acute pulmonary oedema. Since delayed medical treatment leads to poor clinical outcomes, prompt and accurate diagnosis and appropriately timed surgical intervention are essential. This very rare case of severe AR worsening due to spontaneous aortic valve commissure dissection was evaluated with multiple modalities during hospitalization. Understanding this clinical condition will help cardiologists provide better medical care.

Keywords: Aortic regurgitation; Aortic valve commissure detachment; Case report; Localized aortic dissection; Marfan syndrome; Transoesophageal echocardiography.

Publication types

Case Reports