PMC10022526_01
Pre-operative echocardiography. (A) Long-axis view of the left ventricle shows aortic valves thickening and flail motion, and color Doppler shows massive aortic regurgitation. (B) Short-axis view of the great arteries shows that the bulge in the aortic root communicates with the aorta, with vegetations in the aortic valve. (C) The right coronary artery (white arrow) is restrictive; LA, left atrium; LV, left ventricle; RV, right ventricle; AO, aorta; RVOT, right ventricular outflow tract; PA, pulmonary artery; RCA, right coronary artery; AD, aortic disease; and VE, valvular excrescence.
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F1
Echocardiography showed: left ventricle enlargement; a sonolucent area ~11.5 x 25 mm was located next to the right coronary sinus, which communicated with the dilated aortic root; a flail-like moving flocculent vegetation ~17 mm long was located in the junction area of the right and left aortic valve on the aortic side; the right and left aortic valve leaflets were both impaired, resulting in severe aortic regurgitation (Figures 1A, B); and the right coronary artery showed intramural course and was compressed by the surrounding abscess. It also showed an abnormal opening at the junction of the left and right aortic valves, with only a 2.7 mm wide ostium compared to a 4.3 mm one in the left coronary artery (Figure 1C); the ejection fraction was 69%; mild pulmonary hypertension was presented; and no obvious abnormality was observed in the aortic arch and its branches.
Pre-operative computed tomography. (A) Irregular morphology of the coronary sinuses with local anterior protrusion (blue arrow). (B) A three-dimensional reconstruction image shows that the left coronary artery arises from above the left coronary sinus and the right coronary artery arises from above the junction of the left and right coronary sinuses. The aortic root bulge is shown in the blue arrow. (C) Sagittal view showing the vertical position of the bulge (blue arrow).
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F2
Enhancement was observed in the cystic structure, which communicated with the aorta (Figure 2A); the left coronary artery arose from above the left coronary sinus; the right coronary artery arose from above the junction of the left and right coronary sinus, and the proximal segment was surrounded by the abscess (5.1 x 2.0 cm), resulting in mild-to-moderate stenosis (Figures 2B,
Intraoperative findings. (A) The aortic root bulge (blue arrow) filled with vegetation and damaged at the right coronary annulus (black arrow). (B) Intraoperative removal of the damaged aortic valve and part of the annulus (red arrow).
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F3
The bulge communicated with the aortic root and was also full of vegetation, which compressed the right coronary sinus and blocked the right coronary ostia (Figure 3A). Surgical debridement was performed to clear all vegetation and remove the damaged aortic valve leaflets and part of the valvular annulus (Figure 3B).
Post-operative echocardiography. (A) The position and function of the artificial valved conduit are normal. (B) The aortic root bulge is successfully closed without an internal blood flow signal.
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F4
Post-operative echocardiography showed that the artificial aortic conduit and valves were in normal position and functioned well (Figure 4A). The closure of the bulge was successful, with no blood flow signal inside (Figure 4B).