Dynamic Shape Change of an Aortic Valve Cusp Perforation on 3D Transesophageal Echocardiogram

Abstract

A 67-year-old male patient presented to emergency department
with worsening altered mental status and fever. Computerized
tomography (CT) of head found patient with multiple basal ganglia
infarcts with high suspicion for septic emboli as sources for stroke.
Blood cultures and lumbar puncture obtained and the patient was
found to have Streptococcus pneumonia meningitis. A two-dimensional
(2D) transthoracic echocardiogram (TTE) demonstrated severe
aortic regurgitation and flail leaflet with an ejection fraction of
70%. Cardiology and cardiothoracic surgery were consulted for
the valvulopathy in conjunction with elevated troponins, bacteremia,
and bacterial meningitis. A transesophageal echocardiogram
(TEE) showed a perforation of the right coronary cusp resulting
in severe aortic regurgitation (Figures 1A and 1B), a reversal of
flow into the thoracic aorta due to the severe aortic regurgitation
and reduction in ejection fraction from the time the TTE was performed.
His hospital course was further complicated with newonset
of atrial fibrillation. Three-dimensional (3D) TEE provided
an exceptional understanding of the changing size and shape of
the perforation of the cusp with the cardiac cycle (Figures 1C and
1D). While there are methods to assess the regurgitant orifice area
by the 2D echo to determine the severity of aortic regurgitation,
the 3D data clearly shows that the regurgitant orifice is a highly
dynamic structure with the change in shape and size influenced by
systole and diastole. A perforated cusp is a major structural abnormality
and carries with it severe regurgitation. While 3D imaging
in our case may not have altered the management of the patient, it
did enhance the understanding of the pathology from an imaging
perspective and challenges the 2D echo-derived assumption of a
fixed regurgitant orifice