Quick Fire Cases
Melisa Inquilla-Coyla, MD
FELLOW
INSTITUTO NACIONAL DE CARDIOLOGIA IGNACIO CHAVEZ, Mexico
Melisa Inquilla-Coyla, MD
FELLOW
INSTITUTO NACIONAL DE CARDIOLOGIA IGNACIO CHAVEZ, Mexico
Miguel Cruz, MD
Medical physician of cardiac magnetic resonance
National Institute of Cardiology "Ignacio Chávez", Mexico
Aloha Meave Gonzalez, MD
Chair
Instituto Cardiologia, Mexico
Cayo Miguel Angel Leveau-Luján, MD, MSc
Fellow of Cardiac Magnetic Resonance and Angiotomography
National Institute of Cardiology "Ignacio Chávez", Mexico
20-year-old patient from Michoacan, with a job as a laborer, with no medical history or family history.
One month before his evaluation, he suddenly presented resting palpitations, which lasted 6 hours, for which he went to a cardiological evaluation.
On physical examination, forceful apex beat displaced to the left, a systolic aortic murmur radiating to the sternal notch and carotid arteries.
Diagnostic Techniques and Their Most Important Findings:
On echocardiogram, a bicuspid aortic valve (anterior-posterior phenotype) was found with severe valvular stenosis associated with an ascending aortic aneurysm and aortic coarctation.
Cardiac magnetic resonance was performed, which confirmed the diagnosis and, using the 4D sequence, the turbulent helical flow in the ascending aortic aneurysm and a jet of flow in the posterior Valsalva sinus, which is directed towards the right atrium corresponding to the rupture of said sinus, were observed. Other findings included: left ventricular hypertrophy. Normal left ventricular systolic function and moderate right ventricular dysfunction.
In addition, the pre-surgical coronary angiography found a single left coronary artery which arose from the anterior sinus (circumflex artery irrigating the right coronary territory, with the right coronary artery absent).
A Palmaz stent was placed at the coarctation site, followed by surgical repair using the Bental and Bono technique. The patient had a favorable post-surgical evolution.
Learning Points from this Case:
Bicuspid aortic valve is a relatively common congenital malformation, associated with other comorbidities such as aortic coarctation, aortic aneurysms, dissections, valvular lesions, both stenosis and insufficiency.
4D magnetic resonance imaging is a noninvasive imaging technique that allows quantitative and qualitative assessment of patients with aortic valve disease.
It becomes a useful tool in the multidirectional assessment of flow in these patients, allowing the evaluation of outflow to the aorta in vivo, associating flow patterns with complications such as aneurysm or dissection.
The outflow in patients with bicuspide aortic valve becomes eccentric, with increased vortex formation and turbulent flow in the aortic root, which becomes more pronounced as the aortopathy progresses. This alteration of the outflow increases the risk of aortic complications; the quantification of this flow dynamics and its visual alterations are potential predictors of such complications.
We present the case of a young man with bicuspid aortic valve with aortopathy: aneurysm of the ascending aorta who also presented rupture of one of the sinuses of Valsalva which could be evaluated in the 4D flow sequence.
4D flow sequences have allowed us to better understand the physiology of aortic flow and promise to be a useful tool also in the post-surgical follow-up of patients, allowing the determination of flow alterations and the risk of remodeling of the vascular wall.
