Author + information
- Yasir Abdul Ghaffar, MD,
- Yasmin Hamirani, MD,
- Mohammad Adnan Alkhouli, MD,
- Chris Cook, MD and
- Partho P. Sengupta, MD∗ (, )@ppsengupta1
- Department of Cardiovascular and Thoracic Surgery, Heart and Vascular Institute, West Virginia University School of Medicine, Morgantown, West Virginia
- ↵∗Address for correspondence:
Dr. Partho P. Sengupta, West Virginia University Heart and Vascular Institute, 1 Medical Center Drive, Morgantown, West Virginia 26506-8059.
The authors report a case of 85-year-old male undergoing transcatheter aortic valve replacement (TAVR), whose intraoperative transesophageal echocardiogram was concerning for ascending aortic dissection. Further imaging, however, delineated this to be an aortic valve tendon and the TAVR was accomplished successfully. (Level of Difficulty: Advanced.)
- aortic dissection
- aortic stenosis
- aortic valve tendon
- congenital aortic band
- supra-aortic membrane
- transcatheter aortic valve replacement
- transesophageal echocardiography
A supra-aortic tendon is a rare occurrence and can be challenging to distinguish from aortic dissection. We present a case of 85-year-old man with a past medical history of hypertension, hyperlipidemia, and abdominal aortic aneurysm who was referred to our structural heart team at West Virginia University Heart and Vascular Institute in Morgantown, West Virginia for transcatheter aortic valve replacement (TAVR). His transthoracic echocardiogram showed mild left ventricular dysfunction with an ejection fraction of 45%, a mean pressure gradient of 32 mm Hg, a stroke volume index of 31 ml/m2, and a calculated aortic valve area of 0.9 cm2, consistent with low-flow, low-gradient, and severe aortic valve stenosis with reduced ejection fraction.
The patient was elected for TAVR. During the intraoperative transesophageal echocardiogram, concern was raised about the presence of a localized ascending aortic root dissection. The procedure was temporarily halted for careful review of the aortogram and imaging data, including the pre-TAVR computed tomography scan. The computed tomography images also revealed a thin linear shadow stretching across the commissure of the noncoronary and left coronary cusp in a dilated aortic root (Figures 1A to 1C). Further interrogation with transesophageal echocardiography showed that linear bands were originating from the commissure between the noncoronary and left coronary cusp and extending to the sinotubular junction (Figures 1D to 1F, Videos 1 and 2). An aortogram was performed and showed no features to suggest aortic dissection (Video 3). After heart team discussion, this structure was concluded to be consistent with an aortic valve tendon, and TAVR was accomplished.
Post-implantation, the tendon was seen to be pushed on the side with the leaflet, with no evidence of obstruction or extension on color flow (Figures 1G to 1I, Videos 4 and 5). To the best of our knowledge, this is the first case of an aortic valve tendon encountered during TAVR that had a close anatomic resemblance to aortic root dissection. Supra-aortic membrane or tendon mimicking aortic dissection is scarce in current published reports (1–3). Although extremely rare, it may pose challenges during TAVR that necessitate careful anatomic delineation using transesophageal echocardiography.
Dr. Sengupta is an advisor to Heart Sciences, Ultromics, and Hitachi. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 4, 2019.
- Accepted May 4, 2019.
- 2019 The Authors