1. Aortic Regurgitation
secondary to RCC
prolapse
Dr Hannah ZR McConkey
Cardiology Specialist Registrar
Dr Laszlo Halmai
Consultant Cardiologist
Dr Bernard Prendergast
Consultant Cardiologist
Milton Keynes and Oxford UK

2. Medical History
• 38 year old man
• No significant past medical history, including rheumatic fever
• Referred to cardiology outpatient clinic with a history of
dyspnoea for several weeks
• Non smoker
• No alcohol
• No cardiac family history

3. On Examination
• Well
• Physical examination
•
•
•
•
•
BP 128/55mmHg
HR 74 beats / min
No signs of congestive heart failure
Collapsing pulse
Diastolic murmur
• ECG

4. 2D Transthoracic Echocardiography
• Parasternal long axis and parasternal short axis views
•
Suspicious bicuspid aortic valve with doming of the cusps

5. 2D Transthoracic Echocardiography – M Mode

6. 2D Transthoracic Echocardiography
• 3 chamber view showing
eccentric jet of severe
aortic regurgitation (AR)
resulting in restricted
movement of the anterior
mitral valve leaflet
• Severely dilated left
ventricle (130mls/m2)
with well preserved
systolic function
RV
RA

7. 2D Transthoracic Echocardiography
Diastolic flow
reversal in the
descending aorta

8. Management
• Cardiac Catheterisation
• Normal coronary arteries
• LVEDP 30mmHg
• Aortogram: normal ascending aorta and arch, with severe AR filling the
left ventricle within one heart cycle
• Preserved left ventricular (LV) systolic function
• Transoesophageal Echocardiogram
• Moderate -severe LV dilatation with mildly impaired global systolic
function
• The right coronary cusp appears to prolapse on 3D imaging with
resulting very eccentric, anteriorly directed regurgitation restricting the
opening of the anterior mitral valve leaflet

9. Transoesophageal Echocardiogram

10. Transoesophageal Echocardiogram

11. 3D Transoesophageal Echocardiography

12. 3D Transoesophageal Echocardiography
Watch video

13. Treatment: Aortic Valve Replacement
• Native aortic valve
•
•
•
•
Tricuspid
3 commissures
Fusion of the left and right cusps
Redundant prolapsing right cusp
• Repair attempted
• Opening of fused commissure
• Augmentation of valve leaflets at each commissure
• Plication of redundant tissue at mid-point of right cusp
• TOE result poor - valve replaced with 25mm Medtronic
mechanical prosthesis

14. Diagnosis:
Aortic regurgitation secondary to
pseudo-bicuspid aortic valve with
prolapsing right coronary cusp

15. Aortic valve prolapse
• Aortic regurgitation can result from either leaflet
dysfunction or dilatation of any component of the annulus
• Leaflet dysfunction can be described as type 2 (leaflet
prolapse) or type 3 (leaflet restriction)1
• Cusp prolapse is strictly defined as motion of the cusp free
margin below the level of the middle of the sinuses of
Valsalva
• Prolapse of the right coronary or non-coronary cusps is
significantly more common than of the left coronary cusp2
• Leaflet prolapse is more common in bicuspid valves3
1.
2.
3.
Boodhwania M, de Kerchoveb L, Glineurb D, Noirhommeb P, El Khouryb, 2009. Repair of aortic valve
cusp prolapse. MMCTS 2009, Issue 0702
Price J, De Kerchove L, El Khoury G, 2011. Aortic valve repair for leaflet prolapse. Semin Thorac
Cardiovasc Surg 23(2):149-51
El Khoury G, Vanoverschelde JL, Glineur D, et al., 2006. Repair of bicuspid aortic valves in patients with
aortic regurgitation. Circulation 2006;114(1 Suppl.):I610-I616

16. Echocardiographic Features of Cusp Prolapse1
• Eccentric aortic regurgitant jet in the opposite
direction of the prolapsing cusp
• Visualization of the valve cusp below the level of
the aortic annulus during diastole
• Diminished length of aortic leaflet coaptation

17. Repair-Oriented Functional Classification
of Aortic Insufficiency1

18. Leaflet Prolapse Repair with Central Plication
4. de Kerchove L et al, 2008. Eur J Cardiothorac Surg;34:785-791

19. TAKE HOME MESSAGES
• Aortic leaflet prolapse can arise in bicuspid
and tricuspid aortic valves
• Bicuspid aortic valves are more commonly
affected
• Eccentric jets of aortic regurgitation may be
difficult to evaluate and severity is easily
under-estimated
• Transoesophageal echocardiography is key to
determining the severity of aortic
regurgitation and underlying mechanism
• Aortic valve repair may be attempted in
experienced centres and by an experienced
surgeon but the adequacy of the result must
be checked intra-operatively

20. Join the ESC Working Group
on Valvular Heart Disease
and take part in its
activities !
Membership is FREE!