ILLUSTRATIVE ECHOCARDIOGRAM

Echocardiographic Examination in Aortic ~egurgitation*

Subaortic Aneurysm and Flail Aortic Leaflet

WilliamH.Gaasch, M.D.;** and Richurd I. Cleveland, M.D., F.C.C.P.t

Echocardiographic examination of the left ventricular outflow tract in a patient with aortic regurgitation revealed distinct and unusual findings representing diastolic prolapse of an aortic leaflet, in association with a subaortic aneurysm.

The patient was a 23-year-old man who was well until the age of 18 years, when he returned to the continental United States from Viet Nam because of fever and recurrent painful swelling of the knees. A cardiac murmur was heard, and he was treated for bacterial endocarditis. The clinical findings were consistent with moderately severe aortic regurgitation, the lack of obiective but because of the lack of svrnDtornsand * progression of the disease, the patient was observed without cardiac catheterization for five years. Because of the recent development of an awareness of precordial activity, the patient was hospitalized for elective cardiac catheterization. Findings from the physical examination were consistent with impressive aortic regurgitation; the electrocardiogram revealed left ventricular hypertrophy by voltage criteria ouly; the chest x-ray film, including the cardiac silhouette, was normal. Echocardiographic examination was performed, using an ultrasonic scope (Smith, Kline Ekoline 2UA) and a 2.25-MHz transducer 0.5 inch in diameter, focused at 7.5 cm. The patient was studied in the supine position; the transducer was placed in the intercostal space, which allowed recording of the free edge of the mitral valve with the transducer oriented perpendicular to the chest wall. Tracings were recorded on strip charts using a photographic recorder ( Irex). The echocardiogram and angiograms are shown in Figures 1 and 2. Multiple disorganized echoes originated from the posterior wall of the aorta. These dense intenupted echoes tended to parallel the anterior wall of the aorta and appeared to project posteriorly toward the left atrium. Wide separation of the aortic leaflets was seen during systole, and diastolic vibrations of the leaflet echoes were seen from the aorta to the level of the mitral annulus. The left atrial dimension was *From Tufts University School of Medicine and the New England Medical Center Hospital, Boston. This work was supported in part by a research grant-in-aid from 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 Center Hospital, 171 Harrison, Boston 021 11

3.3 cm; the left ventricular enddiastolic dimension was 6.4 cm, a d the change in left ventricular dimension from end of diastole to end of systole was 30 percent. Except for trivial flutter of the anterior leaflet, the mid valve was normal. At cardiac catheterization, the central aortic pressure was 156/40 rnm Hg, and the left ventricular end-diastolic pressure was 16 mm Hg. The ventricle was moderately enlarged (enddiastolic volume, 155 ml/sq m of body surface area), and the systolic ejection fraction was 67 percent. An aneurysm filled with contrast material was seen posterior to the aortic valve (visualized in both the right and left anterior oblique projecf tions, Fig 2)and was believed to represent an aneurysm o the sinus of Valsalva. Severe aortic regurgitation was demonstrated. At the time of aortic valvular replacement, the noncom nary aortic cusp was fenestrated and was draped loosely into the left ventricular outflow tract. The valve was tricuspid. Under this distorted leaflet tissue, the ostium of a subaortic aneurysm was found; the orifice measured 2 an in diameter. The aneurysm was calcified and measured approximately 5 cm in outer diameter. Inspection of the subaortic area revealed that the aneurysm occupied a position posterior to the noncomnary sinus of Valsalva. It did not involve the coronary arteries or other cardiac chambers or valves. The orifice of the aneurysm was closed with a Dacron patch, and the aortic valve was replaced in the usual manner. The patient did well and was discharged on the ninth day after surgery; he is currently asymptomatic.

The value of echocardiographic examination of the left ventricular outflow area has been well documented in a broad spectrum of acquired and congenital abn~rmalities.~" In the present report, we have described the echocardiographic findings in a patient with chronic aortic regurgitation who was found to have a subaortic aneurysm of the left ventricular outflow tract and a fenestrated, flail noncoronary aortic leaflet. Echocardiographic manifestations of aneurysm of the right sinus of Valsalva have been previously described by Rothbaum and associates7 and by Weyman and colleag~es.~ They emphasized that the clinical, hemodynarnic, and echocardiographic manifestations of aneurysm of the sinus of Valsalva

CHEST, 70: 6, DECEMBER, 1976

ECHOCARDIOGRAPHIC EXAMINATION I N AORTIC REGURGITATION 771

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FIGURE 1. Echocardiogram showing interrupted M-mode scan of heart from aorta (Ao) to left
ventricle ( LV). Upper left, Dense interrupted echoes from posterior wall of aorta Upper right, As transducer is directed toward left ventricle, these disorganized echoes ( a m ) are seen only in systole. Lower panel, Vibrations of aortic leaflet are seen in aorta, and portions of these echoes (arrows) persist at level of mitral annulus. At surgery, noncoronary aortic cusp was fenestrated and was hanging freely in subvalvular area, and ostium of subaortic aneurysm was located just inferior to noncoronary aortic cusp.

depended on the size and precise location of the defect. Our patient reinforces this concept. Before surgery the findings from echocardiographic and angiographic studies were believed to represent an aneurysm of the noncoronary sinus of Valsalva; the error in precise preoperative diagnosis resulted from our inability to localize the ostium of the aneurysm to the subvalvular area. Diastolic vibrations of aortic leaflet echoes in the left ventricular outflow tract have only recently been reported by W r a ~He . ~ points out that this finding is highly suggestive of "at least partial disruption of one or more aortic leaflets.'8 In our patient the echocardiographic findings of prolapse of vibrating aortic-leaflet tissue into the left ventricular outflow tract were associated with a subaortic aneurysm, and the echocardiographic and anatomic correlations
772 GAASCH, CLEVELAND

were confirmed at the time of surgery. Angiographic examination of the left ventricular outflow tract, especially with regard to flail or vibrating leaflets, or both, may not be entirely adequate in patients such as the one whose findings are reported herein. Since the injected contrast material obliterates the leaflets and much of the outflow tract in aortic insdciency, detailed anatomic definition of aortic leaflets is often precluded. Cardiac catheterization and angiographic studies remain the standards by which most patients are evaluated for cardiac surgery, but a combination of the hemodynamic and 'ultrasonic cardiac examinations produces information which is not available by either single technique. Echocardiographic study permits examination of the left ventricular outflow tract, as well as noninvasive assessment of left ventricular function
CHEST, 70: 6, DECEMBER, 1976

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FIGURE 2. Aortic root cineangiogram in left anterior oblique projection (left) and left ventricular i l l e d with contrast angiogram in right anterior oblique projection (right). Aneurysm (arrows) f material is seen posterior to aorta at level of aortic valve. Note marked aortic regurgitation (left). and evaluation of suspected mitral valvular disease, and, thus, should be a routine procedure in the preoperative evaluation of patients with aortic valvular disease. ACKNOWLEDGMENTS: We are indebted to Ms. Linda Woodbury for her technical assistance in obtaining the echocardiograms and to Ms. Deborah Marbut for her assistance in the preparation of this manuscript. 1257,1974 4 Popp RL, Silvennan JF, French JW, et al: E c h d graphic findings in discrete subvalvular aortic stenosis. Circulation 49:226,1974 5 Henry WL, Clark CE, Epstein SE: Asymmetric septa1 hypertrophy: E c h p h i c identification of the . pathognomonic anatomic abnormality of IHSS. Circulation 47:225,1973 6 Murphy KF, Kotler MN, Reichek N, et al: Ultrasound in the diagnosis o f congenital heart disease. Am Heart J 89:638, 1975 7 Rothbaum DA, Dillon JC, Chang S, et al: E c h d o graphic manifestation of right sinus of Valsalva aneurysm. Circulation 49:768,1974 8 Weyman AE, Dillon JC, Feigenbaum H, et al: Premature pulmonio valve opening following sinus of Valsalva aneurysm rupture into the right atrium. Circulation 51:556. 1975 9 Wray TM: The variable echocardiographic features in aortic valve endocarditis. Circulation 52:658,1975

of the aortic valve: 1. Studies of normal aortic valve, aortic stenosis, aortic regurgitation, and mixed aortic valve disease. Br Heart J 36:341,1974 2 Nanda NC, Cramiak R, Shah PM: Diagnwis of aortic root dissection by echocardiography. Circulation 48:506, 1973 3 Usher BW. Goulden D, Murgo JP: Echocardiographic detection of supravalvular aortic stenosis. Circulation 49:

l Freizi 0, Symons C, Yacoub M: y h E -

Salamander and Its Metamorphosis

The tiger salamander, Ambystoma tigrlnum, occurs from New York to California and south to central Mexico and reaches a length of from six to ten inches. In some parts of its geographic range, it fails to metamorphose and reproduces while it is in a larval state. Such a larval form is called axolotl; it was long considered a separate species because the external gills persisted into the adult. However, if an axolotl is fed beef thyroid, even one or two meals, it develops into a land animal, it loses its gills
and becomes an air-breathing salamander. T h i s is not now thought to be a case of retarded evolution, but a secondary specialization for arid regions. Nonmetamorphosing forms arose in all probability from stocks that did undergo metamorphosis. Feeding the hormone (thyroxin) reverses this specialization. Hegner, R W and Stiles, KA: College Zoology (7th ed),New York, Macmillan, 1960

CHEST, 70: 6, DECEMBER, 1976

ECHOCARDIOGRAPHIC EXAMINATION I N AORTIC REGURGITATION 773

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