Acute heart failure due to local dehiscence of aortic wall at aortic valvular commissure

Abstract

Spontaneous dehiscence of the aortic wall at the aortic commissure is not recognized as one of the usual pathological causes of aortic regurgitation. We describe the case of a 56-year-old man with hypertension, who experienced acutely progressive congestive heart failure due to massive aortic regurgitation. Local layer dehiscence around the commissure was noted with partial detachment of the commissure resulting in the loss of commissural support with secondary rupture of a non-coronary cusp, which led to massive aortic regurgitation.

Extremely Localized Aortic Dissection and Intussusception of the Intimal Flap into the Left Ventricle

“…10) Infective endocarditis, aortic dissection, avulsion of the aortic valve commissure, rupture of fibrous strands and so forth should be considered as a cause of acute AR. 11,12) The main problem of this moribund patient was an unclear etiology, although the indication and maneuver of surgery are highly dependent on the diagnosis. Judging from negative laboratory tests and the afebrile state, infective endocarditis was unlikely.…”

Insuficiência aórtica aguda por avulsão de comissura valvar aórtica

“…However, this decision does not seem so simple. As described above, it is common the presence of anatomical factors [4], such as cystic necrosis medium, which predispose to avulsion of the commissure and cannot be detected in a preliminary inspection. The presence of any of these factors could compromise the surgical outcome later, if the valve was preserved.…”

“…Despite the small number of cases reported in the literature, some authors suggest that aortic valve replacement would be the best choice, considering the poor long-term results while preserving the valve in this context [4], compared to the consistent results of aortic valve replacement by bovine pericardium bioprosthesis [5,6]. However, there are reports showing acceptable results using the repair and preservation of the valve [7], although the safety of this technique is not known.…”

Echocardiographic and Surgical Findings of Spontaneous Avulsion of the Aortic Valve Commissure

“…An intimal tear of the aortic wall at one commissure, which allows the simultaneous prolapse of 2 cusps and can cause massive aortic regurgitation, results in sudden severe hemodynamic deterioration. [2][3][4][5][6][7] The usual and well-recognized clinical background is either blunt chest trauma or acute ascending aortic dissection, 1,8,9 usually with hemopericardium and hematoma of the cardiac base.…”

“…12 These age-related pathophysiologic changes reduce the area of the lanula and the affected aortic valve commissure is prone to be overloaded by the diastolic pressure, resulting in detachment from the aortic wall, or the cusp is prone to rupture under excessive diastolic hypertension. However, spontaneous commissural detachment can occur in various age groups even in the 20 s, and at any commissure [2][3][4][5][6][7] (Table 1), probably because spontaneous laceration of the ascending aorta results primarily from a weakness of the aortic wall from extensive medial degeneration. 13 Pathological conditions that can cause commissural detachment include classical syphilitic aortitis, 8 aortitis because of various inflammatory diseases, and aortic medial diseases such as cystic medial necrosis 2 with or without Marfan syndrome, and Ehlers -Danlos syndrome.…”