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LETTERS TO EDITOR
Year : 2021  |  Volume : 15  |  Issue : 2  |  Page : 242-244

Eccentric aortic regurgitation jet: Is it benign or needs attention?


Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Sultanate of Oman

Correspondence Address:
Madan Mohan Maddali
Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, P.B. No: 1331, P.C: 111, Seeb, Muscat
Sultanate of Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.sja_1046_20

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Date of Submission16-Oct-2020
Date of Acceptance16-Oct-2020
Date of Web Publication01-Apr-2021
 


How to cite this article:
Arora NR, Maddali MM. Eccentric aortic regurgitation jet: Is it benign or needs attention?. Saudi J Anaesth 2021;15:242-4

How to cite this URL:
Arora NR, Maddali MM. Eccentric aortic regurgitation jet: Is it benign or needs attention?. Saudi J Anaesth [serial online] 2021 [cited 2021 Apr 21];15:242-4. Available from: https://www.saudija.org/text.asp?2021/15/2/242/312946



Sir,

We report a case of splaying of the left and non-coronary aortic valve cusps resulting in a localized aortic reugitatant jet that created an impression of an aortic cusp perforation.

A 46-year-old female patient [weigh: 86 Kg; height: 147.3 cm] was posted for urgent coronary bypass surgery due to a 90% ostial occlusion of left main coronary artery. Her preoperative transthoracic echocardiography reported no significant regional wall motion abnormalities nor valvulopathies. After administration of general anesthesia under standard American Society of Anesthesiologists recommended monitoring modalities transesophageal echocardiography [TEE] was performed. A color Doppler blood flow map in the mid-esophageal aortic long axis and short-axis views revealed an eccentric turbulence in diastole with a vena contracta of 1.55 mm [[Figure 1]A, [Figure 1]B and Video Clips 1, 2]. The eccentric turbulence was also observed in the aortic valve in the deep trans-gastric view [Video Clip 3]. The aortic root dimensions were normal. The pressure half time was 510 msec. The mid-esophageal aortic short-axis view by 3-D TEE was used to measure the aortic valve individual cusp's area, height and inter-commissural distances [[Figure 1]A1, [Figure 1]B1 and [Figure 1]C1].
Figure 1: A&B&A1&B1&C1. Mid-esophageal aortic long axis transesophageal echocardiography view (A) and mid-esophageal aortic valve short axis view (B) with color Doppler blood flow map showing turbulence in diastole in the upper frame and in the lower frame, 3D mid-esophageal aortic valve short axis transesophageal echocardiography view showing the area of the aortic cusps (A), the height of each aortic cusp (B) and inter-commissure distances at the aortic annulus (C)

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If the localized aortic regurgitation was due to a perforation in an aortic cusp the issues faced by the team were two-fold: 1. Since it's a coronary artery bypass surgery that does not need an aortotomy, a perforation would mandate an aortotomy and inspection of the leaflets. 2. Then there could be a problem with antegrade cardioplegia delivery and undetected left ventricular distension. Hence it was important to investigate the cause for the aortic regurgitation rapidly within a short time before the institution of cardiopulmonary bypass. The vena contracta and the pressure half time measurements indicated that it was a mild aortic regurgitant jet [Figure 1]A. Careful visualization of the aortic valve in the mid-esophageal short-axis view displayed the regurgitation to be along the commissure between the left and the non-coronary cusp of the aortic valve instead of a localized regurgitation as would be the case if there was a perforation in a cusp [[Figure 1]B and Video Clip 2].

The 3D analysis suggested that in this patient the left coronary cusp was larger than the other two. It is assumed that structural, morphologic, and functional interdependence of aortic valve components would be reflected in the relationships that are found between key valve dimensions.[1] Aortic cusp enlargement might be due to congenital factors or it might be due to a remodeling effect of the cusp size as an adaptation mechanism in response to increasing aortic root dimensions.[2],[3] However, the aortic root dimensions were normal in this patient. Hence the exact cause for the eccentric aortic regurgitation seen in mid-esophageal aortic long-axis view is not clear. Probably an elevated mean arterial pressure could have resulted in a coaptation defect between the relatively larger left coronary cusp and the non-coronary cusp creating an impression of an eccentric aortic regurgitation that would have been caused by a fenestration in the aortic cusp.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Subramanian S, Tikhomirov V, Bharati S, ElZein C, Roberson D, Ilbawi MN. Relationship of normal aortic valve cusp dimensions: A tool to optimize cusp reconstruction valvuloplasty. Semin Thorac Cardiovasc Surg 2016;28:521-7.  Back to cited text no. 1
    
2.
Thubrikar MJ, Labrosse MR, Zehr KJ, Robicsek F, Gong GG, Fowler BL. Aortic root dilatation may alter the dimensions of the valve leaflets. Eur J Cardiothorac Surg 2005;28:850-5.  Back to cited text no. 2
    
3.
Kim DH, Handschumacher MD, Levine RA, Sun BJ, Jang JY, Yang DH, et al. Aortic valve adaptation to aortic root dilatation: Insights into the mechanism of functional aortic regurgitation from 3-dimensional cardiac computed tomography. Circ Cardiovasc Imaging 2014;7:828-35.  Back to cited text no. 3
    


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