Secondary Logo

Journal Logo

Two- and Three-Dimensional Transesophageal Echocardiography for Aortic Valve Aneurysms on the Right Coronary Cusp

Kuroda, Masataka MD, PhD*; Takemae, Akihito MD*; Takahashi, Toshikazu MD; Mita, Norikatsu MD; Kagaya, Shin MD, PhD; Miyoshi, Sohtaro MD, PhD; Kadoi, Yuji MD, PhD*; Saito, Shigeru MD, PhD*

doi: 10.1213/ANE.0b013e318284783c
Cardiovascular Anesthesiology: Society of Cardiovascular Anesthesiologists: Echo Rounds
Free
SDC

From the *Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi; and Department of Anesthesiology, Saitama Prefectural Cardiovascular and Respiratory Center, Kumagaya, Japan.

Accepted for publication November 8, 2012.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.anesthesia-analgesia.org).

Reprints will not be available from the authors.

Address correspondence to Masataka Kuroda, MD, PhD, Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan. Address e-mail to m.kurohyou@gmail.com.

A 73-year-old man was scheduled for aortic valve (AV) replacement for severe aortic regurgitation (AR). Preoperative transthoracic echocardiography revealed severe AR due to flail of the right coronary cusp (RCC). No vegetation was observed on the valve and surrounding tissues, inflammatory responses were within normal limits, and preoperative blood cultures were negative. Written informed consent was obtained from the patient for publication of this report and any accompanying images.

Intraoperative transesophageal echocardiography (TEE) was performed using a 3-dimensional (3D) echocardiographic matrix-array probe (X7-2t transducer; Philips Healthcare, Andover, MA). The midesophageal (ME) 4-chamber view demonstrated a saccular structure in the left ventricular (LV) outflow tract (LVOT), and color flow Doppler (CFD) analysis revealed a severe regurgitant jet from nearby, although from a different site on the structure (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A517). An ME AV short-axis view showed a tricuspid AV with a large and deformed RCC (Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A519). With slight advancement of the probe, 2 masses with an echo-free center were scanned at the LVOT, appearing at diastole and disappearing at systole, while CFD demonstrated mosaic blood flow throughout diastole from 1 of the 2 masses (Video 2, http://links.lww.com/AA/A519). On scanning with the ME AV long-axis (LAX) view, the RCC of the AV was seen to be perforated, with severe AR (Video 2, http://links.lww.com/AA/A519). The X-plane mode (Philips Healthcare) was used to assess orthogonal views of each structure in the LVOT. With this, a perforated aneurysm was seen on the RCC (Fig. 1A). Another view seemed to depict an AV aneurysm of the RCC that protruded into the LVOT, with expansion during diastole and collapse during systole (Fig. 1B). A 3D echocardiographic view was constructed from the full-volume mode with 4-beat estimation based on the aortic and LV perspectives.1 From the aortic perspective, 2 circular echo-free areas were seen on the RCC (Fig. 2A) (Video 3, see Supplemental Digital Content 3, http://links.lww.com/AA/A518). To obtain the view from the LV perspective, the image was rotated by approximately 180 degrees, so that the RCC remained at the bottom. Once again, 2 echo-free areas were seen on the RCC and a regurgitant jet was revealed at the site of perforation on the RCC by CFD, while there was no regurgitant jet from the nonperforated aneurysm (Video 3, http://links.lww.com/AA/A518). The other valves, including the mitral valve (MV) and surrounding structures had a normal morphology. During the surgery, the surgeon inspected the AV and confirmed the presence of 2 AV aneurysms on the RCC, one of which was perforated (Fig. 2B). These findings were consistent with those of intraoperative TEE examinations.

Video 1

Video 1

Video 2

Video 2

Figure 1

Figure 1

Figure 2

Figure 2

Video 3

Video 3

The AV was replaced with a bioprosthetic AV, the patient was successfully weaned off cardiopulmonary bypass, and he recovered with an uneventful postoperative course.

Back to Top | Article Outline

DISCUSSION

An AV aneurysm is defined as a localized bulge of the AV cusp toward the LVOT. Although infective endocarditis is a common cause of AV aneurysms,2,3 rheumatoid arthritis4 and bicuspid AVs5 are other possible etiologic factors. Irrespective of the etiology, perforation of the aneurysmal cavity into the LVOT can lead to severe AR.

In previous reports, transthoracic echocardiography and TEE for AV aneurysm revealed a mass with an echo-free center in the LVOT, just below the AV.2–4 Careful observation indicated a saccular aneurysm of the AV, originating from the aortic cusp. It was shown to expand and protrude into the LVOT during diastole and collapse during systole, as was seen in our case as well. In case of aneurysms due to infective endocarditis, MV aneurysms form via spread of infection along the mitral-aortic intervalvular fibrosa or injury to the anterior mitral leaflet via contact with an aortic vegetation. In contrast to AV aneurysms, MV aneurysms are seen to bulge into the left atrium in systole and collapse in diastole.6 Perforation of the aneurysm is usually identifiable during CFD by visualization of a regurgitant jet passing through the perforation.2,3

In our case, 2 masses with an echo-free center were revealed in the LVOT, at the scanning level of which continuity between the masses and cusps of the AV could not be clearly scanned. Both of the masses were scanned with 2D orthogonal LAX views, which confirmed their origin from the RCC. Although slight clockwise or counterclockwise rotation of the TEE probe while scanning the standard 2D LAX view made longitudinal scanning of both the aneurysms possible, the X-plane mode facilitated accurate and detailed visualization of both aneurysms and their associations with surrounding tissues. The X-plane mode enabled scanning of simultaneous orthogonal views by fine and real-time scans by means of the cursor line and by fixing the short-axis view of the 2 simultaneously scanned structures. Furthermore, the 3D en face view allows visualization of the entire AV complex in motion throughout the cardiac cycle, providing additional information on its spatial relationship with surrounding structures.1 In this case, the relationship between the RCC and the 2 aneurysms during diastolic expansion could be displayed in a single view from the aortic and LV perspective. However, whether or not the aneurysms were perforated could not be confirmed, because both aneurysms were seen as masses with an echo-free center.

The information about blood flow through the aneurysms provided by CFD was useful for distinguishing whether or not the aneurysms were perforated, because both 2D and 3D images were unable to scan the bottom of the round and thin wall of the nonperforated aneurysm. Echo dropout led to an apparent defect in the bottom of the aneurysm, as seen in Figures 1B and 2A. Instead, the perforation was obvious in the morphologic view. The X-plane mode with CFD, 3D, and color 3D modes had limitations associated with low frame rate and poor temporal resolution, although the 3D image was reconstructed in full volume with 4-beat estimation.

AV aneurysms need to be distinguished from other causes of aneurysmal formations presenting in the LVOT.7 The differential diagnosis is displayed in Table 1. Detailed scanning of their appearance, origin, and changes in TEE appearance during the cardiac cycle would help differentiation of the different etiologies.

Table 1

Table 1

In conclusion, detailed 2D, X-plane, and 3D TEE analyses complement each other in analyzing the morphologic features of AV aneurysms, and CFD analysis with both 2D and 3D TEE is useful for diagnosing whether or not the aneurysms are perforated.

Back to Top | Article Outline

DISCLOSURES

Name: Masataka Kuroda, MD, PhD.

Contribution: This author helped with design of the study, conduct of the study, data collection, data analysis, and preparation of the manuscript.

Attestation: Masataka Kuroda approved the final manuscript.

Name: Akihito Takemae, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Akihito Takemae approved the final manuscript.

Name: Toshikazu Takahashi, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Toshikazu Takahashi approved the final manuscript.

Name: Norikatsu Mita, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Norikatsu Mita approved the final manuscript.

Name: Shin Kagaya, MD, PhD.

Contribution: This author helped prepare the manuscript.

Attestation: Shin Kagaya approved the final manuscript.

Name: Sohtaro Miyoshi, MD, PhD.

Contribution: This author helped prepare the manuscript.

Attestation: Sohtaro Miyoshi approved the final manuscript.

Name: Yuji Kadoi, MD, PhD.

Contribution: This author helped prepare the manuscript.

Attestation: Yuji Kadoi approved the final manuscript.

Name: Shigeru Saito, MD, PhD.

Contribution: This author helped prepare the manuscript.

Attestation: Shigeru Saito approved the final manuscript.

This manuscript was handled by: Martin J. London, MD.

Back to Top | Article Outline

REFERENCES

1. Lang RM, Badano LP, Tsang W, Adams DH, Agricola E, Buck T, Faletra FF, Franke A, Hung J, de Isla LP, Kamp O, Kasprzak JD, Lancellotti P, Marwick TH, McCulloch ML, Monaghan MJ, Nihoyannopoulos P, Pandian NG, Pellikka PA, Pepi M, Roberson DA, Shernan SK, Shirali GS, Sugeng L, Ten Cate FJ, Vannan MA, Zamorano JL, Zoghbi WAAmerican Society of Echocardiography; European Association of Echocardiography. . EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr. 2012;25:3–46
2. Zhang L, Nguyen J, Epelman S, Prichett A, Dokainish H. Enterococcal endocarditis presenting as an isolated aortic valve aneurysm: case report and review of literature. J Am Soc Echocardiogr. 2008;21:1391.e5–6
3. Azevedo O, Ferreira F, Guardado J, Durães C, Quelhas I, Pereira A, Almeida J. Mitral and aortic valve aneurysms secondary to infective endocarditis: impressive images of a rare echocardiographic finding. Eur J Echocardiogr. 2010;11:E28
4. Alpaslan M, Evcik D, Onrat E. Aortic valve aneurysm: a novel cardiac manifestation of rheumatoid arthritis? J Am Soc Echocardiogr. 2001;14:1137–8
5. Ratib O, Perloff JK, Child JS. Images in cardiovascular medicine: bicuspid aortic valve aneurysm. Circulation. 2004;109:671
6. Stechert MM, Pletcher JR, Tseng EE, London MJ. Echo rounds: aneurysm of the anterior mitral valve. Anesth Analg. 2012;114:86–8
7. Meier JH, Seward JB, Miller FA Jr, Oh JK, Enriquez-Sarano M. Aneurysms in the left ventricular outflow tract: clinical presentation, causes, and echocardiographic features. J Am Soc Echocardiogr. 1998;11:729–45
Back to Top | Article Outline

Clinician’s Key Teaching Points

By Kent H. Rehfeldt, MD, and Roman M. Sniecinski, MD

  • Aortic valve aneurysm presents as a saccular evagination of leaflet tissue appearing in the left ventricular outflow tract (LVOT) during diastole as a mobile mass with an echo-free center. Because of the potential for central echo dropout, aneurysm perforation can be difficult to identify with 2-dimensional imaging; color Doppler flow through the structure most reliably indicates perforation.
  • Other pathologies that appear as outpouchings around the aortic valve include a sinus of Valsalva aneurysm or aortic cusp prolapse. In contrast to aortic valve aneurysm, which appears as an LVOT mass with diastolic expansion, a sinus of Valsalva aneurysm more frequently protrudes into the right atrium or right ventricle and diminishes in size in diastole. Although both aortic cusp prolapse and aortic valve aneurysm appear in the LVOT and may lead to severe aortic regurgitation, a prolapsing aortic cusp is generally thicker and more echogenic than a thin-walled, saccular aneurysm.
  • In this case, it was difficult to establish the origin of the LVOT masses in a single, 2-dimensional imaging plane. By using the X-plane feature to simultaneously scan orthogonal planes and by using 3-dimensional imaging, the authors were able to identify 2 aortic valve aneurysms originating from the right cusp, one of which had ruptured, causing severe aortic regurgitation.
  • Just as 2-dimensional imaging may not adequately demonstrate the structure and anatomical relationships of pathologic valvular masses in all cases, 3-dimensional transesophageal echocardiographic imaging can be hampered by low frame rates and poor temporal resolution. A combination of echocardiographic imaging modalities should be considered in complex cases.

Supplemental Digital Content

Back to Top | Article Outline
© 2013 International Anesthesia Research Society