- Case report
- Open Access
Cardiovascular magnetic resonance of quinticuspid aortic valve with aortic regurgitation and dilated ascending aorta
© Meng et al; licensee BioMed Central Ltd. 2009
Received: 26 March 2009
Accepted: 11 August 2009
Published: 11 August 2009
We report a rare case of a quinticuspid aortic valve associated with regurgitation and dilation of the ascending aorta, which was diagnosed and post-surgically followed up by cardiovascular magnetic resonance and dual source computed tomography.
Aortic valve malformation is a common congenital cardiac anomaly in the adult population. Dysfunction of the malformed aortic valve has been shown to cause significant morbidity and mortality. Among the malformations, bicuspid is the most common form, which has been identified in 1–2% of population with male predominance . To our knowledge, an aortic valve containing 5 leaflets (quinticuspid) is very rare . Here we report a case of quinticuspid aortic valve associated with aortic regurgitation and dilation of the ascending aorta.
Given the aggravating symptoms of aortic insufficiency and imaging finding of aortic valve anomaly, the patient proceeded to receive an aortic valve replacement with a concurrent Robicsek procedure, a surgery of reinforced aortoplasty. The aortic root was transected and the malformed aortic valve was replaced with an ON-X25 mechanical valve (ON-X technologies, Inc., Austin, Texas, USA). A 32 mm artificial vessel was used to enwrap the aortic root with Robicsek procedure. Postoperative CT and CMR scans were performed and showed functional artificial aortic valve with no regurgitations detected (Figure 1g–i).
In congenital aortic anomalies, the number of aortic leaflets can deviate from the normal three leaflets. Bicuspid is the most common form. Uni- and quadricuspids are seen much less frequently [3–6]. To our knowledge, this is the first reported case of quinticuspid aortic valve accompanied with detailed imaging studies.
The cause of this type of aortic valve anomaly is unknown. During embryologic development, the aortic valve normally develops into three commissures and three leaflets. If this process fails, the valve may be less than three cusps. If more than three commissures develop, it would cause a valve with four or more cusps. Valves with abnormal numbers may open improperly to cause stenosis, or may close incompletely resulting in regurgitation. Patients with these abnormalities may expect to develop hemodynamically significant complications at some point in their lifetime. In our case, the patient developed left ventricular chamber dilation and ascending aorta dilation at a relatively young age of 24 years.
CT and CMR have been demonstrated to be effective imaging methods for accurate diagnosis of aortic valve malformation [7–9]. In this case, accurate preoperative diagnosis of aortic valve abnormality was made easier with dual source CT and CMR. CT yielded images with higher spatial and temporal resolution than CMR. We were able to demonstrate detailed anatomy of the quinticuspid aortic valve and size of each sinus of valsalva. However, CMR yielded hemodynamic data in addition, including a detailed assessment of aortic regurgitation with signal changes from the abnormal blood flow. Both CT and MR are useful in postoperative follow-up of the morphology and function of the artificial valve. Although echocardiography is both sensitive and specific in detecting bicuspid aortic valves, it proved to be less useful in this case due to poor echocardiographic windows, and did not identify the 5 closely related leaflets.
In general, patients with known aortic valve anomaly are closely followed up to monitor the symptoms and signs relating to aortic stenosis or insufficiency. The goal is to prevent permanent damage to the left ventricle, or excessive dilation of the ascending aorta leading to aortic dissection and aneurysm. Same cases may necessitate surgical intervention, which commonly include aortic valve replacement with procedures to manage dilated ascending aorta. Given the fact that the currently available valve substitutes are not ideal for young patients, some choose valve repair instead. Tricuspidization is suitable for bicuspid and quadricuspid valves [10–12], and bicuspidization, for unicuspid aortic valves . Our patient was successfully managed with aortic valve replacement with a Robicsek procedure for aortic root narrowing.
In summary, we have illustrated an unusual case of quinticuspid aortic valve in a young adult presented with aortic regurgitation, left ventricular enlargement, and dilation of the ascending aorta. This case also demonstrates the value of CT and CMR in the diagnosis of this condition.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
YM, MD, Fellow of Radiology. LZ, MD, Resident of Radiology. ZZ, MD, Professor and Chairman of Radiology. YW, MD, Associated professor of Radiology. XY, MD, PhD, Professor and Director of Image-Guided Bio-Molecular Interventions Research, Radiology
Authors want to thank Hongxiu Ji, MD, PhD for her editorial assistance.
- Cannata A, Lanfranconi M, Vitali E, Garatti A, Bonacina E: Is aortic wall degeneration related to bicuspid aortic valve anatomy in patients with valvular disease?. J Thorac Cardiovasc Surg. 2008, 136: 937-942. 10.1016/j.jtcvs.2007.11.072.View ArticlePubMedGoogle Scholar
- Bogers JJ, Aytug Z, Hendriks FF, Huysmans HA: Quinticuspid aortic valve causing aortic valve incompetence and stenosis. Thorax. 1982, 37 (7): 542-3. 10.1136/thx.37.7.542.PubMed CentralView ArticlePubMedGoogle Scholar
- Bansal A, Arora S, Traub D, Haybron D: Univuspid aorta valve and aortic arch aneurysm in a patient with Turner syndrome. Asian Cardiovasc Thorac Ann. 2008, 16: 266-267.View ArticlePubMedGoogle Scholar
- Hor KN, Border WL, Cripe LH, Benson DW, Hinton RB: The presence of bicuspid aortic valve does not predict ventricular septal defect type. Am J Med Genet A. 2008, 146A: 3202-3205. 10.1002/ajmg.a.32609.PubMed CentralView ArticlePubMedGoogle Scholar
- Yildirim SV, Gümüş A, Coşkun I, Türköz R: Quadricuspid aortic valve: a rare cause of aortic regurgitation and stenosis. Turk J Pediatr. 2008, 50: 500-502.PubMedGoogle Scholar
- Feldman BJ, Khandheria BK, Warnes CA, Seward JB, Taylor CL, Tajik AJ: Incidence, description and functional assessment of isolated quadricuspid aortic valves. Am J Cardiol. 1990, 65: 937-938. 10.1016/0002-9149(90)91446-D.View ArticlePubMedGoogle Scholar
- Debl K, Djavidani B, Buchner S, Poschenrieder F, Heinicke N, Schmid C, Kobuch R, Feuerbach S, Riegger G, Luchner A: Unicuspid aortic valve disease: a magnetic resonance imaging study. Rofo. 2008, 180: 983-987.View ArticlePubMedGoogle Scholar
- Ucar O, Vural M, Cicekcioglu H, Pasaoglu L, Aydogdu S, Koparal S: Case report: Multidetector CT presentation of a parachute-like asymmetric mitral valve. Br J Radiol. 2008, 81: e266-e268. 10.1259/bjr/20218809.View ArticlePubMedGoogle Scholar
- Gleeson TG, Mwangi I, Horgan SJ, Cradock A, Fitzpatrick P, Murray JG: Steady-state free-precession (SSFP) cine MRI in distinguishing normal and bicuspid aortic valves. J Magn Reson Imaging. 2008, 28: 873-878. 10.1002/jmri.21547.View ArticlePubMedGoogle Scholar
- Kawazoe K, Izumoto H, Tsuboi J, Koizumi J: Tricuspidization of incompetent bicuspid aortic valve. J Thorac Cardiovasc Surg. 2003, 126: 908-910. 10.1016/S0022-5223(03)00391-X.View ArticlePubMedGoogle Scholar
- McMullan DM, Oppido G, Davies B, Kawahira Y, Cochrane AD, d'Udekem d'Acoz Y, Penny DJ, Brizard CP: Surgical strategy for the bicuspid aortic valve: tricuspidization with cusp extension versus pulmonary autograft. J Thorac Cardiovasc Surg. 2007, 134: 90-98. 10.1016/j.jtcvs.2007.01.054.View ArticlePubMedGoogle Scholar
- Schmidt KI, Jeserich M, Aicher D, Schäfers HJ: Tricuspidization of the quadricuspid aortic valve. Ann Thorac Surg. 2008, 85: 1087-1089. 10.1016/j.athoracsur.2007.09.016.View ArticlePubMedGoogle Scholar
- Schäfers HJ, Aicher D, Riodionycheva S, Lindinger A, Rädle-Hurst T, Langer F, Abdul-Khaliq H: Bicuspidization of the unicuspid aortic valve: a new reconstructive approach. Ann Thorac Surg. 2008, 85: 2012-2018. 10.1016/j.athoracsur.2008.02.081.View ArticlePubMedGoogle Scholar
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