© 2015 Wiley Periodicals, Inc.
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CARDIAC SURGERY _____________________________________________________
Malformed Aortic Valve Mimicking Type A Aortic Dissection Stephane Leung Wai Sang, M.D., M.Sc.,* Kevin E. Hodges, B.Sc.,* Michael Majewski, M.D.,y and Sukit Chris Malaisrie, M.D.* *Division of Cardiac Surgery, Northwestern Memorial Hospital, Chicago, Illinois; and yDepartment of Anesthesiology, Northwestern Memorial Hospital, Chicago, Illinois doi: 10.1111/jocs.12534 (J Card Surg 2015;30:452)
CASE REPORT A 73-year-old woman presenting with chest pain underwent electrocardiogram-gated computed tomography angiogram of the aorta, which showed a localized flap of the left coronary sinus without aortic dilatation, suspicious for type A dissection (Fig. 1). The patient was subsequently taken for surgical repair. Intraoperative transesophageal echocardiography suggested a dissection flap in the left sinus of Valsalva, in addition to severe subvalvular aortic stenosis (peak gradient 100 mmHg), a hypertrophic septum, and systolic anterior motion of the mitral valve suggesting hypertrophic obstructive cardiomyopathy. Upon direct inspection, there was no evidence of dissection. Rather, the left coronary cusp of the aortic valve appeared rudimentary with predominance of the right and noncoronary cusps (Fig. 2). We proceeded with aortic valve replacement using a 23 mm Magna Ease (Edwards Lifesciences, Irvine, CA, USA), septal myectomy, mitral valve repair with an Alfieri stitch, and pulmonary vein isolation with bipolar frequency ablation. Aortic valve replacement was performed due to mild leaflet calcification and the abnormal nature of the cusps. Postoperatively, the patient developed complete heart-block necessitating a permanent pacemaker before being discharged home on day 10.
Conflicts of interest: S.C. Malaisrie reports lecture fees from Edwards Lifesciences and Medtronic. There was no external funding obtained for this case report. Address for correspondence: S. Chris Malaisrie, M.D., Northwestern Memorial Hospital, Galter Room 11-140, 201 E Huron, Chicago IL 60611. Fax: 312-695-1903; e-mail: [email protected]
Figure 1. Computed tomography angiogram demonstrating aortic dissection at the left coronary sinus (arrowhead).
Figure 2. Intraoperative assessment of the aortic valve revealing an abnormal left coronary cusp (arrowhead). Inset: Resected aortic valve leaflets (L, left coronary cusp; R, right coronary cusp; N, noncoronary cusp).
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
452
IMAGES
IN
CARDIAC SURGERY _____________________________________________________
Malformed Aortic Valve Mimicking Type A Aortic Dissection Stephane Leung Wai Sang, M.D., M.Sc.,* Kevin E. Hodges, B.Sc.,* Michael Majewski, M.D.,y and Sukit Chris Malaisrie, M.D.* *Division of Cardiac Surgery, Northwestern Memorial Hospital, Chicago, Illinois; and yDepartment of Anesthesiology, Northwestern Memorial Hospital, Chicago, Illinois doi: 10.1111/jocs.12534 (J Card Surg 2015;30:452)
CASE REPORT A 73-year-old woman presenting with chest pain underwent electrocardiogram-gated computed tomography angiogram of the aorta, which showed a localized flap of the left coronary sinus without aortic dilatation, suspicious for type A dissection (Fig. 1). The patient was subsequently taken for surgical repair. Intraoperative transesophageal echocardiography suggested a dissection flap in the left sinus of Valsalva, in addition to severe subvalvular aortic stenosis (peak gradient 100 mmHg), a hypertrophic septum, and systolic anterior motion of the mitral valve suggesting hypertrophic obstructive cardiomyopathy. Upon direct inspection, there was no evidence of dissection. Rather, the left coronary cusp of the aortic valve appeared rudimentary with predominance of the right and noncoronary cusps (Fig. 2). We proceeded with aortic valve replacement using a 23 mm Magna Ease (Edwards Lifesciences, Irvine, CA, USA), septal myectomy, mitral valve repair with an Alfieri stitch, and pulmonary vein isolation with bipolar frequency ablation. Aortic valve replacement was performed due to mild leaflet calcification and the abnormal nature of the cusps. Postoperatively, the patient developed complete heart-block necessitating a permanent pacemaker before being discharged home on day 10.
Conflicts of interest: S.C. Malaisrie reports lecture fees from Edwards Lifesciences and Medtronic. There was no external funding obtained for this case report. Address for correspondence: S. Chris Malaisrie, M.D., Northwestern Memorial Hospital, Galter Room 11-140, 201 E Huron, Chicago IL 60611. Fax: 312-695-1903; e-mail: [email protected]
Figure 1. Computed tomography angiogram demonstrating aortic dissection at the left coronary sinus (arrowhead).
Figure 2. Intraoperative assessment of the aortic valve revealing an abnormal left coronary cusp (arrowhead). Inset: Resected aortic valve leaflets (L, left coronary cusp; R, right coronary cusp; N, noncoronary cusp).
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
