Case Report
A 26-year-old man was found to have cardiomegaly on chest x-ray on a
routine pre-employment health check-up. He was asymptomatic with no
history suggestive of any cardiac illness or any pre-existing
co-morbidity. He did not have a history of fever, weight loss, drug
abuse or rheumatic fever. However, on repeated interrogation he
remembered blunt trauma to his face and chest due to a vehicular
accident 2 years ago. He did not have a Marfanoid habitus. The BP was
140/40 mm Hg. The pulse rate was 100/min, regular and collapsing in
character; pistol shot sounds were also present. A Grade 4/6 high
pitched moderately long diastolic murmur was heard in the left third
intercostal space.
Echocardiography revealed a moderately dilated left ventricle with
normal systolic function. There was severe AR with significant diastolic
reversal of flow in descending thoracic aorta. The aortic valve was
tri-leaflet, with no significant dilation of the aortic root (Video 1).
The Effective Regurgitant Orifice of the AR jet by the Proximal
Isovelocity Surface Area method was 0.5 cm2 with a
regurgitant volume of 96 ml/beat. The pressure half time of the AR jet
was only 250 ms. The right coronary leaflet appeared elongated and the
NAL showed everted edges (Video 2). There was no evidence of rheumatic
affection or endocarditis.
We performed a Trans Esophageal Echocardiography (TEE) to delineate the
etiology of AR and aortic valve pathology. Normal tri-leaflet valve and
aortic root were confirmed (Figure1, Video 3) and there was evidence of
tissue gap in the NAL suggestive of perforation (Figure 2). There was no
vegetation. Colour Doppler study
confirmed severe AR with two AR
jets being clearly visualised, one through the point of incomplete
coaptation and other one through the perforated area in the NAL (Figure
3; Videos 4). He underwent surgery; intra-operatively the large
perforation of the NAL was confirmed (Figure 4). There was no evidence
of endocarditis or calcification. The valve was replaced with a 21 mm St
Jude Trifecta tissue valve. Post-operative recovery was uneventful, and
he is doing well at 18 months follow up.