Abstract
WEBSITE FEATURE
A 57-year-old man with a history of uncontrolled hypertension, diabetes mellitus, and renal transplantation presented with acute pulmonary edema and syncope. A loud blowing diastolic murmur was heard at the right upper sternal border. Transthoracic echocardiography showed moderate-to-severe aortic regurgitation (AR) with a vena contracta width of 0.9 cm and a 40% ratio of color Doppler jet width to left ventricular (LV) outflow tract width. There was concentric LV hypertrophy with normal LV systolic function, a dilated left atrium (5.1 cm), and moderate LV diastolic dysfunction. Transesophageal echocardiography (TEE) revealed a normal-appearing trileaflet aortic valve, a normal thoracic aorta, and severe AR. Throughout ventricular diastole, blood flowed from the left main coronary artery into the aorta (Fig. 1). Coronary angiography showed normal coronary arteries.
Fig. 1 A) Transesophageal echocardiographic short-axis view of the aortic valve and left main coronary artery (arrow) in diastole. B) Color Doppler shows flow away from the left main coronary artery into the aortic valve (arrow) during diastole.
Real-time motion image is available at www.texasheart.org/journal.
The patient underwent successful aortic valve replacement with a 23-mm On-X® bileaflet mechanical valve (On-X Life Technologies, Inc; Austin, Texas). The immediate postoperative TEE showed a normally functioning prosthetic valve with no AR and no diastolic flow reversal in the left main coronary artery. The excised aortic valve showed mild focal fibrous thickening, mainly at the free margins (Fig. 2).
Fig. 2 Pathology specimen shows a tricuspid aortic valve with mildly thickened margins.
Comment
Diastolic flow reversal in the descending aorta is a well-known Doppler echocardiographic marker of severe AR.1 Ardehali and colleagues2 reported a reversal in diastolic coronary blood flow during the administration of papaverine in closed-chest dogs with experimental acute severe AR. However, to our knowledge, diastolic left main coronary flow reversal in human beings has not been previously described. The normal coronary flow pattern is predominantly diastolic3 but can change to systolic predominance in the setting of severe AR.2 Subendocardial ischemia in patients with chronic severe AR and normal coronary arteries occurs, presumably as a result of low aortic diastolic pressure combined with elevated wall stress.2,4 Although our patient did not have clinical, electrocardiographic, or biochemical evidence of coronary ischemia, the holodiastolic coronary flow reversal evident on the color-flow images was striking. This case serves as a reminder that coronary flow patterns should not be overlooked during TEE.
Supplementary Material
Footnotes
Address for reprints: Paul A. Grayburn, MD, Baylor Heart and Vascular Institute, 621 N. Hall St., #H030, Dallas, TX 75226-1312
E-mail: paulgr@baylorhealth.edu
References
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