Echo Case Ao Regurg

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ILLUSTR TIVE ECHOC RDIOGR MEchocardiographic Examination in Aortic ~egurgitationSubaortic Aneurysm and Flail Aortic LeafletilliamH Gaasch,M.D.; nd Richurd I Cleveland,M.D., F.C.C.P.t

Echocardiographic examination of the left ven- 3.3 cm; the left ventricular enddiastolic dimension was 6.4tricular outflow tract in a patient with aortic cm, d he change in left ventricular dimension from end ofdiastole to end of systole was 30 percent. Except for trivialregurgitation revealed distinct and unusual findings flutter of the anterior leaflet,the mid valve was normalrepresenting diastolic prolapse of an aortic leaflet, in At cardiac catheterization, the central aortic pressure wasassociation with a subaortic aneurysm. 156/40 rnm Hg, and the left ventricular end-diastolic pressure

The patient was a 23-year-old man who was well until theage of 18 years, when he returned to the continental UnitedStates from Viet Nam because of fever and recurrent painfulswelling of the knees. cardiac murmur was heard, and hewas treated for bacterial endocarditis. The clinical findingswere consistent with moderately severe aortic regurgitation,but because of the lack of svrnDtornsand the lack of obiectiveprogression of the disease, the patient was observed withoutcardiac catheterization for five years. Because of the recentdevelopment of an awareness of precordial activity, thepatient was hospitalized for elective cardiac catheterization.Findings from the physical examination were consistent withimpressive aortic regurgitation; the electrocardiogram re-vealed left ventricular hypertrophy by voltage criteria ouly;the chest x-ray film, including the cardiac silhouette, wasnormal.

Echocardiographic examination was performed, using anultrasonic scope (Smith, Kline Ekoline 2UA) and a 2.25-MHztransducer 0.5 inch in diameter, focused at 7.5 cm. Thepatient was studied in the supine position; the transducerwasplaced in the intercostal space, which allowed recording ofthe free edge of the mitral valve with the transducer orientedperpendicular to the chest wall. Tracings were recorded onstrip charts using a photographic recorder Irex)

The echocardiogram and angiograms are shown in Figuresand 2. Multiple disorganized echoes originated from the

posterior wall of the aorta. These dense intenupted echoestended to parallel the anterior wall of the aorta and appearedto project posteriorly toward the left atrium. Wide separationof the aortic leaflets was seen during systole, and diastolicvibrations of the leaflet echoes were seen from the aorta tothe level of the mitral annulus. The left atrial dimension was

*From Tufts University School of Medicine and the NewEngland Medical Center Hospital, Boston.This work was supported in part by a research grant-in-aidfrom the American Heart Association, Greater Boston,Massachusetts Ch ter-1320.O 'Department of ~ 3 i c i n e .tDepartment of Surgery.Reprint requests: Dr. Gaasch, New England Medical CenterHosp ital, 171 H arrison, Boston 021 11

was 16 mm Hg. The ventricle was moderately enlarged (end-diastolic volume, 155 ml/sq m of body surface area), and thesystolic ejection fraction was 67 percent. An aneurysm filledwith contrast material was seen posterior to the aortic valve(visualized in both the right and left anterior oblique projec-tions, Fig 2)and was believed to represent an aneurysm ofthe sinus of Valsalva. Severe aortic regurgitation wasdemonstrated.

At the time of aortic valvular replacement, the noncomn ry aortic cusp was fenestrated and was draped loosely intothe left ventricular outflow tract The valve was tricuspid.Under this distorted leaflet tissue, the ostium of a subaorticaneurysm was found; the orifice measured 2 n n diameter.The neurysm was calcified and measured approximately 5m in outer diameter. Inspection of the subaortic area re-

vealed that the aneurysm occupied a position posterior to thenoncomnary sinus of Valsalva. It did not involve the coronaryarteries or other cardiac chambers or valves. The orifice ofthe aneurysm was closed with a Dacron patch, and the aorticvalve was replaced in the usual manner. The patient did welland was discharged on the ninth day after surgery; he iscurrently asymptomatic.

The value of echocardiographic examination ofthe left ventricular outflow area has been welldocumented in a broad spectrum of acquired andcongenital abn~rmalit ies .~ n the present report,we have described the echocardiographic findings ina patient with chronic aortic regurgitation who wasfound to have a subaortic aneurysm of the left ven-tricular outflow tract and a fenestrated, flail non-coronary aortic leaflet.

Echocardiographic manifestations of aneurysm ofthe right sinus of Valsalva have been previouslydescribed by Rothbaum and associates7 and byWeyman and colleag~es.~hey emphasized thatthe clinical, hemodynarnic, and echocardiographicmanifestations of aneurysm of the sinus of Valsalva

CHEST 7 : 6 DECEMBER 1976 ECHOCARDIOGRAPHIC EXAMINATION I N AORTIC REGURGITATION 771

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FIGURE Echocardiogram showing interrupted M-mode scan of heart from aorta Ao) to leftventricle LV). Upper left ense interrupted echoes from posterior wall of aorta Upper rightAs transducer is directed toward left ventricle, these disorganized echoes a m ) re seen onlyin systole. Lower panel Vibrations of aortic leaflet are seen in aorta, and portions of theseechoes arrows) persist at level of mitral annulus. At surgery, noncoronary aortic cusp w sfenestrated and w s hanging freely in subvalvular area, and ostium of subaortic aneurysm waslocated just inferior to noncoronary aortic cusp.

depended on the size and precise location of thedefect. Our patient reinforces this concept. Beforesurgery the findings from echocardiographic andangiographic studies were believed to represent ananeurysm of the noncoronary sinus of Valsalva; theerror in precise preoperative diagnosis resulted fromour inability to localize the ostium of the aneurysmto the subvalvular area.

Diastolic vibrations of aortic leaflet echoes in theleft ventricular outflow tract have only recently beenreported by W r a ~ . ~e points out that this finding ishighly suggestive of at least partial disruption ofone or more aortic leaflets.'8 In our patient theechocardiographic findings of prolapse of vibratingaortic-leaflet tissue into the left ventricular outflowtract were associated with a subaortic aneurysm, andthe echocardiographic and anatomic correlations

were confirmed at the time of surgery.Angiographic examination of the left ventricular

outflow tract, especially with regard to flail or vibrat-ing leaflets, or both, may not be entirely adequate inpatients such as the one whose findings are reportedherein. Since the injected contrast material obliter-ates the leaflets and much of the outflow tract inaortic insdciency, detailed anatomic definition ofaortic leaflets is often precluded. Cardiac catheter-ization and angiographic studies remain the stan-dards by which most patients are evaluated for car-diac surgery, but a combination of the hemodynamicand 'ultrasonic cardiac examinations produces in-formation which is not available by either singletechnique. Echocardiographic study permits exam-ination of the left ventricular outflow tract, as well asnoninvasive assessment of left ventricular function

77 GAASCH CLEVELAND CHEST 70: 6 DECEMBER 197 6



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FIGURE. Aortic root cineangiogram in left anterior oblique projection left) and left ventricularangiogram in right anterior oblique projection right).Aneurysm arrows) fille with contrastmaterial s seen posterior to aorta at level of aortic valve. Note marked aortic regurgitation left).an d evaluation of suspected mitral valvular disease,and, thus, should be a routine procedure in thepreoperative evaluation of patients with aorticvalvular disease.ACKNOWLEDGMENTS: We are indebted to Ms. LindaWoodbury for her technicalassistance in obtaining the echo-cardiograms and to Ms. Deborah Marbut for her assistance inthepreparation of this manuscript

l Freizi 0 Symons C, Yacoub M: E of theaortic valve: 1. Studies of normal aortic valve, aorticstenosis, aortic regurgitation, and mixed aortic valve dis-ease. Br Heart J 36:341,19742 Nanda NC, Cramiak R, Shah PM: Diagnwis of aortic rootdissection by echocardiography. Circulation 48:506, 19733 Usher BW. Goulden D, Murgo JP: Echocardiographicdetection of supravalvular aortic stenosis. Circulation 49:

1257,19744 Popp RL, Silvennan JF, French JW t al: E c h dgraphic findings in discrete subvalvular aortic stenosis.Circulation 49:226,19745 Henry WL Clark CE, Epstein SE: Asymmetric septa1hypertrophy: Ech-phic identification of the

. pathognomonic anatomic abnormality of IHSS. Circulation47:225,19736 Murphy KF,Kotler MN, Reichek N, et al: Ultrasound inthe diagnosis of congenital heart disease. Am Heart J89:638, 19757 Rothbaum DA, Dillon JC, Chang S, et al: E c h d o -graphic manifestation of right sinus of Valsalva aneurysm.Circulation 49:768,19748 Weyman AE,Dillon JC, Feigenbaum H et al: Prematurepulmonio valve opening following sinus of Valsalvaaneurysm rupture into the right atrium. Circulation 51:556.19759 Wray TM: The variable echocardiographic features inaortic valve endocarditis. Circulation 52:658,1975

Salamander and Its MetamorphosisThe tiger salamander, Ambystoma tigrlnum, occursfrom New York to California and south to central Mexicoand reaches a length of from six to ten inches. In someparts of its geographic range, it fails to metamorphoseand reproduces while it is in a larval state. Such a larvalform is called axolotl; it was long considered a separatespecies because the external gills persisted into the adult.However, if an axolotl is fed beef thyroid, even one ortwo meals, it develops into a land animal, it loses its gills

and becomes an air-breathing salamander. This is notnow thought to be a case of retarded evolution, but asecondary specialization for arid regions. Nonmetamor-phosing forms arose in all probability from stocks that didundergo metamorphosis. Feeding the hormone thyrox-in) reverses t is specialization.Hegner, R W nd Stiles,KA:CollegeZoology 7thed New York, Macmillan,1960

CHEST 70: 6, DECEMBER, 1976 ECHOC RDIOGR PHIC EX MIN TION I N ORTIC REGURGIT TION 77


Echo Case Ao Regurg

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