Blunt Traumatic Injury to the Aortic Root and Aortic Valve
On hospital day 8, he was scheduled for aortic valve replacement surgery. Intraoperative transesophageal echocardiography (TEE) demonstrated severe AI in the midesophageal (ME) aortic valve long- and short-axis views (Figure 1; Supplemental Digital Content 1, Video 1, http://links.lww.com/AA/B893). A small pericardial effusion was also present. No vegetation was visualized on the aortic valve and the left ventricle was normal size. The etiology for the patient’s AI was prolapse of the noncoronary cusp (NCC) with a jet directed away from the prolapsing cusp (Figure 1; Supplemental Digital Content 1, Video 1, http://links.lww.com/AA/B893). The prolapsing cusp was identified as the NCC by turning the probe shaft clockwise in the ME aortic valve long-axis view, which typically brings the NCC into view compared to the left coronary cusp (LCC), which is brought into view by turning the probe shaft counterclockwise.
Two-dimensional (2D) echocardiography in the ME aortic valve short-axis view further demonstrated an out-pouching in the aortic root just above the aortic valve annulus (Figure 2A). Three-dimensional (3D) echocardiography confirmed this defect, which was directly above the origin of the right coronary cusp (RCC) and NCC commissure (Figure 2B; Supplemental Digital Content 2, Video 2, http://links.lww.com/AA/B894). 3D imaging confirmed no vegetation was present. Comprehensive TEE examination did not show other abnormalities.
The patient was cannulated centrally for cardiopulmonary bypass and had standard aortic cross clamping. Surgical inspection of the valve and aortic root demonstrated traumatic contained rupture (pseudoaneurysm) of the aorta just above the RCC and NCC commissure. The rupture was contained by aortic adventitia, which prevented cardiac tamponade. Primary surgical repair of the aortic tear was performed in conjunction with aortic valve replacement and the patient had an excellent outcome.