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.