2020 年 11 巻 1 号 p. 31-36
Background: Aortic regurgitation (AR) can complicate acute aortic dissection (AAD). Treatment requires differentiation between AR that was present before onset of the AD and not directly involved in the dissection and AR that occurred as a result of ascending aorta dilatation associated with the AD. We encountered a case of AD accompanied by AR for which replacement of the ascending aorta was indicated on the basis of initial transesophageal echocardiography (TEE) findings and exploration of the surgical field. Despite aortic replacement, the AR persisted, requiring aortic valvuloplasty (AVP).
Case presentation: The patient was a 67-year-old woman (height,162 cm; weight, 67 kg) with Stanford type A AAD. Preoperative TEE revealed an aortoventricular junction (AVJ) of 18 mm, an effective height (eH) of 7 mm, sinuses of Valsalva of 38 mm, and a sino-tubular junction of 39 mm, together indicating severe AR. There was no pericardial effusion, and the ejection fraction was 60%. The eH throughout the surgical field measured 8 mm, and the AVJ measured 24 mm. AR resulting from dilatation of the ascending aorta was diagnosed, and we simply replaced the ascending aorta. Immediately after removal of the cross-clamp, we observed moderate central valvular regurgitation as well as a trace AR jet emanating from the commissure between the left and noncoronary cusps, so we performed AVP (involving central plication and 20-mm suture annuloplasty) to treat the residual AR. After central plication, the eH measured 8 mm throughout the field, and TEE performed after discontinuation of cardiopulmonary bypass revealed an AVJ of 19 mm, an eH of 8 mm, sinuses of Valsalva of 31 mm, and an STJ of 23 mm, confirming that the AR was resolved.
Conclusion: Our case illustrates the importance of determining, during the initial intraoperative TEE evaluation of patients undergoing surgery for AAD, a need for AV management and the advisability of AVP. Comprehensive TEE evaluation is called for—evaluation that includes not only measurement of the aortic complex, the eH, and coaptation lengths, but also measurement of the short axis of the valve leaflets and the extent of dissection.
