Acute aortic dissection with intimal layer prolapse into the left ventricle.

A 34-year-old male presented with acute onset of searing chest pain and was preoperatively diagnosed with a Type A dissection limited to the ascending aorta and arch. His preoperative troponin levels were not elevated. The patient was scheduled for urgent repair of a Type A ascending aorta and transverse arch dissection under hypothermic circulatory arrest using selective antegrade cerebral perfusion. The intraoperative transesophageal echocardiogram (TEE) examination was performed using the Philips 5500 ultrasound machine with a Philips OmniPlane III ultrasound probe. Multiple views of the left ventricle (LV) revealed a large intimal flap, prolapsing several centimeters into the LV outflow tract during diastole. Severe (4 ) aortic insufficiency (AI) was diagnosed with color flow Doppler, but regurgitant flow was contained within the prolapsing, intimal “sock.” No evidence of regurgitant flow beyond the prolapsed intimal layer in the LV outflow tract was demonstrated (Fig. 1). The LV was dilated with moderate, global hypokinesis. No regional wall motion abnormalities were noted and the ejection fraction was estimated at 40%. Careful comparison of the aortic valve (AV) in midesophageal (ME) long axis, and ME AV short axis (SAX) views suggested functional, bicuspid leaflet excursion, mild thickening, and no significant leaflet calcification or stenosis. The aorta was 2.6 cm at the AV annulus, 4.8 cm at the sinus of Valsalva, 7.2 cm at the sino-tubular junction, and larger than 7.5 cm in the visualized portion of the ascending aorta. Surgical inspection confirmed the diagnosis of bicuspid AV. The left/right coronary cusp was partially fused with a congenital cleft from the midportion to the free leaflet edge. The intima of the sinus of Valsalva was 80% circumferentially torn, with an anchor point surrounding the left main coronary ostia. The surgeon performed a valve-sparing aortic root replacement using the David V re-implantation technique with 32-mm Gelweave Valsalva graft (Vascutek USA Inc). The valve annulus was reduced in circumference with an aortic valvuloplasty, and the AV cusp cleft was closed with interrupted sutures. A button re-implantation of the left coronary ostia into the graft was possible. The right coronary ostium was partially disrupted, and a saphenous vein graft bypass was performed. The patient was successfully weaned after 304 min of cardiopulmonary bypass, including 27 min of deep hypothermic circulatory arrest. Moderate inotropic support was required. The cardiac function was depressed from baseline to an estimated 30% ejection fraction. No new-onset regional wall motion abnormalities were demonstrated. The postcardiopulmonary bypass TEE examination revealed a functional bicuspid valve with good excursion of leaflets and no subsequent aortic insufficiency. Planimetry of the effective orifice area measured 2.10 cm in the ME AV SAX view. This planimetry measurement closely correlated with the calculated effective orifice area of 2.20 cm using the continuity equation. The patient’s postoperative course was uneventful. Transthoracic echocardiogram prior to discharge from the hospital showed an ejection fraction of 40%–45% with no AI.