Emergency Computed Tomography for Aortic Valve Vegetation Mimicking Disruption
Markus Weininger, MD,
Cagatay Yildirim, MD1,
Christian Ritter, MD,
Rainer Leyh, MD1,
Dietbert Hahn, MD,
Matthias Beissert, MD
Department of Radiology
1 Department of Cardiothoracic Surgery University Hospital of Wuerzburg Wuerzburg, Germany
Markus Weininger, MD, Tel: +49 931 201 34201, Fax: +49 931 201 61860, Email: weininger{at}roentgen.uni-wuerzburg.de, University Hospital of Wuerzburg, Department of Radiology, Oberduerrbacher Strasse 6, 97080 Wuerzburg, Germany.
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ABSTRACT
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A 47-year-old man presented with symptoms typical of infective endocarditis and history of streptococcal meningitis 8 months previously. Echocardiography showed a large aortic valve vegetation that was interpreted as disruption of the noncoronary cusp. This was ruled out by 64-slice cardiac computed tomography. Valve replacement was performed successfully.
Key Words: Aortic Valve • Aortic Valve Insufficiency • Heart Valve Prosthesis Implantation • Echocardiography • Tomography • X-Ray Computed
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INTRODUCTION
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Echocardiography has been recommended as the method of choice for noninvasive assessment of cardiac valves.1 However, additional imaging might be necessary in some cases. The use of 64-slice cardiac computed tomography (CT) for rapid noninvasive evaluation of the valve apparatus and the coronary artery tree was recently described in the consensus statement of the North American Society of Cardiac Imaging and the European Society of Cardiac Radiology.2 This was exemplified by a case of subacute aortic valve endocarditis and suspected disruption of the noncoronary aortic cusp, in which emergency cardiac CT established the preoperative diagnosis and helped to determine the surgical procedure.
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CASE REPORT
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A 47-year-old man was admitted to our emergency department with recent onset of subfebrile temperatures up to 38.6°C associated with shortness of breath and headaches. His history was remarkable for streptococcal meningitis 8 months earlier, which was related to prior dental treatment, and successfully resolved by intravenous administration of cephalosporin. He had no coronary risk factors. Clinical examination revealed a 4/6 systolic heart murmur. Blood cultures grew a Gram-positive coccobacillus that was phenotypically identified as Abiotrophia defectiva. Based on these findings, a diagnosis of subacute aortic valve endocarditis was made. Transthoracic echocardiography revealed normal left ventricular function without hypokinesia, but there were soft vegetations on the aortic valve and moderate aortic valve insufficiency. Transesophageal echocardiography indicated vegetations on the noncoronary cusp (13 x7 mm in size) and left coronary cusp (6x3 mm in size), causing severe aortic insufficiency. Transesophageal echocardiography also showed suspected disruption of the noncoronary aortic cusp (Figure 1
). For further evaluation of this critical aortic valve condition, and to solve the discrepancy between transthoracic and transesophageal echocardiography, 64-slice cardiac CT was performed using a Sensation 64 (Siemens Medical Solutions, Erlangen, Germany). After careful image reconstruction, thickening and vegetations on the aortic cusps were detected. Disruption of the noncoronary aortic cusp could be ruled out, and thus the emergency aspect of the case was alleviated. No paravalvular abscess or leakage was seen.
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Figure 1. Echocardiographic images in parasternal long-axis view, revealing a large aortic valve vegetation (white arrows) mimicking disruption of the noncoronary aortic cusp.
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The aortic bulbus was measured as 35 mm (Figure 2). Cardiac CT also rule out coronary artery disease. On the basis of the CT findings, the decision for aortic valve replacement was made, and the patient was scheduled for routine surgery. The Ross procedure without additional coronary bypass grafting was chosen. The operative findings confirmed the CT findings. The postoperative course was unremarkable, and the patient was discharged from hospital 9 days after surgery.
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Figure 2. Computed tomography clearly depicting thickening of the noncoronary cusp. (A) Right anterior oblique view revealing thickening of the noncoronary cusp of the aortic valve (arrow heads). (B) The cranial view and (C) left anterior oblique cranial orientation visualize the aortic valve apparatus in other projections. The vegetations on the valve were detected (arrow heads) and disruption of the noncoronary cusp could be excluded. In addition, the chordae tendineae (arrows) of the mitral valve were visible.
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DISCUSSION
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The exact anatomy of the valve apparatus and the presence of coronary artery disease are essential in deciding treatment for valvular heart disease. Especially in complex cases, cardiac CT is valuable in noninvasive cardiac assessment, with the potential to improve the management of selected patients with acute chest pain.2,3 Cardiac CT can provide detailed information on cardiac morphology and topography, beyond that provided by echocardiography. Furthermore, cardiac CT combines detailed examination of the valve apparatus with the capacity to rule out coronary disease in a single examination, which is helpful in emergency situations.2
In our patient, 64-slice CT ruled out the suspected disruption of the noncoronary aortic cusp indicated by echocardiography. Therefore, emergency surgery was avoided. Furthermore, CT assessment of the coronary arteries revealed no disease. Because of these reliable CT findings, cardiac catheterization was unnecessary. In the Ross procedure, the patient’s diseased aortic valve is replaced by their own pulmonary valve. The pulmonary valve is then replaced with a cryopreserved cadaveric pulmonary valve. During this procedure, the patient’s coronary arteries need to be re-inserted.4–7 In patients with coronary artery disease, coronary bypass surgery might be necessary. In this patient, bypass grafting could be avoided as coronary artery disease was ruled out pre-operatively, and less extensive surgery could be planned.
Cardiac CT is a reliable imaging modality nowadays, not only in the assessment of coronary arteries but also of cardiac valves. It provides additional information in acute care to clarify diagnoses and potentially avoid the need for additional cardiac catheterization.
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REFERENCES
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- Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ ASE Committee to Update the (1997) Guidelines for the Clinical Application of Echocardiography). Circulation 2003;108:1146–62.[Free Full Text]
- Stillman AE, Oudkerk M, Ackerman M, Becker CR, Buszman PE, de Feyter PJ, et al. Use of multidetector computed tomography for the assessment of acute chest pain: a consensus statement of the North American Society of Cardiac Imaging and the European Society of Cardiac Radiology. Eur Radiol 2007;17:2196–207.[Medline]
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- Ross DN. Replacement of the aortic and mitral valves with a pulmonary autograft. Lancet 1967;2:956–8.[Medline]
- Simon P, Aschauer C, Moidl R, Marx M, Keznickl FP, Eigenbauer E, et al. Growth of the pulmonary autograft after the Ross operation in childhood. Eur J Cardiothorac Surg 2001;19:118–21.[Abstract/Free Full Text]
- Moidl R, Simon P, Aschauer C, Chevtchik O, Kupilik N, Rödler S, et al. Does the Ross operation fulfill the objective performance criteria established for new prosthetic heart valves? J Heart Valve Dis 2000;9:190–4.[Medline]
- Kouchoukos NT, Davila-Roman VG, Spray TL, Murphy SF, Perrillo JB. Replacement of the aortic root with a pulmonary autograft in children and young adults with aortic-valve disease. N Engl J Med 1994;330:1–6.[Medline]
Asian Cardiovasc Thorac Ann 2010;
18:68-70
© 2010 by SAGE Publications
DOI: 10.1177/0218492309343725
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ABSTRACT
INTRODUCTION
