Pivotal Role of Intraoperative Transesophageal Echocardiography for Detecting Iatrogenic Aortic Regurgitation due to Cardiac Catheterization.

A 67-year-old man with a history of fatigue and dyspnea on exertion was diagnosed with atrial fibrillation and severe mitral regurgitation. Preoperative transthoracic echocardiography (TTE) showed a normal aortic valve without aortic regurgitation (Figure 1 and Supplementary Video 1) and bileaflet mitral valve prolapse with severe mitral regurgitation. As part of the preoperative evaluation, cardiac catheterization was performed, which showed normal coronary arteries. The patient was referred for mitral valve repair.

Figure 1

Transthoracic echocardiogram, showing a normal aortic valve without aortic regurgitation.

Ao = aorta; LV = left ventricle.

Intraoperative transesophageal echocardiography (TEE) before sternotomy showed a moderate, unexpected eccentric jet of aortic regurgitation (Figure 2 and Supplementary Video 2). The preoperative left ventriculogram showed the multipurpose guiding catheter intermittently entering the aortic sinus (Figure 3 and Supplementary Video 3). Because aortic regurgitation was not present before catheterization, the catheter likely caused trauma to the aortic leaflet, resulting in aortic regurgitation. Two areas with defects were found during surgery: an apparent cleft in the right coronary cusp and a tear in the central right coronary cusp (Figure 4A). Aortic valve repair consisted of commissuroplasty between the right and noncoronary cusps, repair of the tear in the right coronary cusp, and resuspension of all 3 commissures (Figure 4B). Mitral valve repair, ligation of the left atrial appendage, and surgical CryoMaze of the left atrium were performed as planned. Follow-up TTE showed insignificant aortic regurgitation, trivial mitral regurgitation, and normal left ventricular ejection fraction.

Figure 2

Intraoperative transesophageal echocardiogram before surgery, showing aortic regurgitation.

Ao = aorta; LA = left atrium; LV = left ventricle.

Figure 3

Cineangiogram during contrast injection of the left ventriculogram. (A) Left ventricular catheter (arrow) just below the right coronary cusp. (B) Left ventricular catheter (arrow) just above the right coronary cusp.

Figure 4

Intraoperative image. (A) Tear in the right coronary cusp (arrows). (B) Aortic valve repair (arrows).

Iatrogenic aortic regurgitation due to cardiac catheterization is a rare complication most often associated with aortic dissection.1) Few cases have been reported of iatrogenic aortic regurgitation due to aortic leaflet trauma during cardiac catheterization.2)3)4) This case highlights the importance of intraoperative TEE in identifying unexpected findings such as aortic regurgitation secondary to iatrogenic aortic valve cusp trauma.