alexa Aortic Regurgitation due to Commissural Dehiscence of the Aortic Valve | Open Access Journals
ISSN: 2155-9880
Journal of Clinical & Experimental Cardiology
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Aortic Regurgitation due to Commissural Dehiscence of the Aortic Valve

Ken Okamoto and Toshihiro Fukui*
Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
Corresponding Author : Toshihiro Fukui, MD
Department of Cardiovascular Surgery
Kumamoto, University Hospital, 1-1-1 Honjo
Kumamoto City, Kumamoto 860-8556, Japan
Tel: +81-96-373-5202
Fax: +81-96-373-5207
E-mail: [email protected]
Received: December 17, 2015 Accepted: January 28, 2016 Published: January 30, 2016
Citation: Okamoto K, Fukui T (2016) Aortic Regurgitation due to Commissural Dehiscence of the Aortic Valve. J Clin Exp Cardiolog 7:415. doi: 10.4172/2155-9880.1000415
Copyright: © 2016 Okamoto K, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

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.

Keywords
Aortic surgery; Aortic regurgitation; Aortic valve surgery; Aortic root
Introduction
Commissural dehiscence of the aortic valve is a rare cause of aortic regurgitation. This condition has been documented in only a few case reports [1-5]. Commissural dehiscence of the aortic valve is occasionally found intraoperatively because preoperative diagnosis of this condition is difficult. We report a case of commissural dehiscence of the aortic valve that caused aortic regurgitation and aortic root dilatation.
Case
A 53-year-old man was admitted to our hospital with congestive heart failure. He had dyspnea on exertion 1 month before referral to our hospital. His symptoms improved after use of diuretic drugs. Transthoracic echocardiography demonstrated severe aortic regurgitation and moderate mitral regurgitation with left ventricular dilatation (left ventricular diastolic dimension, 67 mm; left ventricular systolic dimension, 50 mm). Contrast-enhanced computed tomography (CT) showed dilatation of the aortic root (sinus of Valsalva, 45 mm). A flap or intimal tear of the proximal aorta was absent with echocardiography and CT. Transesophageal echocardiography(TEE) was performed to assess the cause of aortic regurgitation. TEE revealed prolapse of the right and left coronary cusps (Figure 1) with no intimal flap in the ascending aorta. Surgery was planned after medical control of heart failure.
Median sternotomy was performed. When the pericardium was opened, serous effusion was observed. Moreover, tight adhesion between the ascending aorta and pulmonary artery was observed. Cardiopulmonary bypass was performed with ascending aortic and bicaval venous cannulations.
After the adhesion around the ascending aorta was dissected, an aortic clamp was applied and cardiac arrest was obtained. Mitral annuloplasty with a semi-rigid ring (size, 30 mm) was performed. The body temperature was decreased to 25°C, systemic perfusion was temporarily arrested, and retrograde cerebral perfusion was started. The ascending aorta was resected, and replaced with a 26-mm Triplex graft (Vascutek Terumo, Tokyo, Japan) with one branch. After completion of distal aortic anastomosis, systemic perfusion through the side branch of the graft was resumed. 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 (Figure 2). Valve leaflets were slightly atherosclerotic, and the aortic wall was normal. We performed aortic root replacement with a commercially available composite valved conduit (25–28 mm; Carboseal, CarboMedics, Austin, TX). The postoperative course was uneventful and no neurological deficit occurred.
Discussion
Commissural dehiscence of the aortic valve is a rare cause of aortic regurgitation. Aortic regurgitation sometimes occurs secondary to acute aortic dissection. Aortic leaflet prolapse occurs when dissection extends into the aortic root, and disrupts normal attachment of leaflets to the aortic wall. In the present case, prolapse of the right and left aortic leaflets occurred by dehiscence of the commissure between the right and left aortic cusps. This condition has been documented in only a few case reports [1-5]. Although the cause of aortic commissural dehiscence is unknown, hypertension is considered to be the most likely cause [3].
Aortic valve replacement with or without fixation of the dehiscent aortic wall is a common procedure [1-3]. Another treatment of choice is aortic root replacement [1,4,5]. In the present case, aortic root replacement with a valved conduit was performed because the aortic root and ascending aorta were dilated. An aortic valve-sparing operation may be an alternative procedure in patients without heart failure and other cardiac procedures (mitral valve annuloplasty and ascending aortic replacement).
In conclusion, commissural dehiscence of the aortic valve is a rare cause of aortic regurgitation. We should take this condition into account when prolapse of the aortic cusp is the cause of aortic regurgitation.
References

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Review summary

  1. Samantha
    Posted on Aug 02 2016 at 5:04 pm
    The manuscript presents an interesting case of commissural dehiscence with adequate presentation, surgical and imaging detail. The article provides an integrated appraisal of the relevant literature which provides a clear picture regarding the context for the study. The article is of high interest to practicing cardiologists and will help in the development of advanced therapies for cardio logical diseases.
 

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