Martin Penicka ECHOLAB Cardiovascular Center, OLV Ziekenhuis, Aalst, Belgium

1. Case of the month: Severe AI; 5 2011
Rare cause of severe aortic
insufficiency
Martin Penicka
ECHOLAB
Cardiovascular Center, OLV Ziekenhuis, Aalst, Belgium
martin.penicka@olvz-aalst.be
dinsdag 20 september 2011

2. Case of the month: Severe AI; 5 2011
CASE description
• 51 years old sportsman referred for AI
• 1995 murmur
• 1999 moderate AI
• 2006 severe AI
• Clinical examination: length 1.86 m, weight 98 kg
• No symptoms (validated with exercise test, regular sport)
• No coronary artery disease at coronary angiography
• No significant commorbidities
dinsdag 20 september 2011

3. Case of the month: Severe AI; 5 2011
Echo-Doppler examination: 3D echo jet
3D reconstruction of vena contracta
3D color Doppler shows
confirmed severe AI with an effective
severe AI (grade 3+/4)
regurgitant orifice of 34 mm²
ERO 34 mm²
dinsdag 20 september 2011

4. Case of the month: Severe AI; 5 2011
Echo-Doppler examination: 3D echo jet
3D reconstruction of vena contracta
3D color Doppler shows
confirmed severe AI with an effective
severe AI (grade 3+/4)
regurgitant orifice of 34 mm²
ERO 34 mm²
dinsdag 20 september 2011

5. Case of the month: Severe AI; 5 2011
Etiology of AI: guadricuspid aortic valve
dinsdag 20 september 2011

6. Case of the month: Severe AI; 5 2011
Etiology of AI: guadricuspid aortic valve
dinsdag 20 september 2011

7. Case of the month: Severe AI; 5 2011
Quadricuspid aortic valve
• The aortic valve may be unicuspid, bicuspid, tricuspid, or quadricuspid
• The quadricuspid aortic valve (QAV) is the rarest from congenital
abnormalities of the aortic valve cusps
• Incidence at autopsy 0.008%
• Incidence during AVR 1%
• First description in 1862, since then only 190 cases in the literature
• If dysfunctional the dysfunction is usually pure AI
• Aortic stenosis with a QAV is exceedingly rare
Hurwitz, Am J Cardiol 1973
Roberts, Am J Cardiol 2007
Timperly, Clinic Cardiol 2002
Tutarel, J Heart Valve Dis 2004
dinsdag 20 september 2011

8. Case of the month: Severe AI; 5 2011
Is this patient with severe AI indicated
for aortic valve surgery ?
Summary of the case
• No exercise limitation or symptoms (validation with exercise test)
• No coronary artery disease or significant disease of other valves
• Normal LVEF (LVEF = 65%)
• No LV dilatation (LVEDd = 48 mm, LVESd = 24 mm)
• No aortic root (36 mm) or aorta ascedens (37 mm) dilatation
At this moment, no indication for aortic valve surgery (see next slide)
Follow-up (Cardiology, Echo, Exercise test) recommendations:
•1 x year if EF, LV and aortic diameters are stable
•1 x 6 months in case of deterioration or when close to the threshold
for surgery
dinsdag 20 september 2011

9. Case of the month: Severe AI; 5 2011
Guidelines: indication for surgery
A) Severe aortic regurgitation
1. Symptomatic patients IB
2. Asymptomatic patients (validation using exercise test)
a) LVEF ≤ 50% IB
b) LVEDd > 70 mm or
LVESd > 50 mm (LVESd index > 25 mm/m²) IIaC
3. Cardiac surgery for other reason (CABG, other valve, asc aorta) IC
B) Whatever the severity of AI in pts with significant aortic root / aorta
disease:
Marfan’s syndrome: Ao ≥ 45 mm (≥ 23 cm/m²) IC
Bicuspid AV: Ao ≥ 50 mm (≥ 25 cm/m²) IIaC
Other patients: Ao ≥ 55 mm (≥ 28 cm/m²) IIaC
C) AVR may be considered in patients with moderate AI while
undergoing CABG or other valve surgery IIbC
ESC guidelines, Eur Heart J 2007
ACC/AHA guidelines, Circulation 2008
dinsdag 20 september 2011