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J Thorac Cardiovasc Surg 1994;107:1539-1540
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

A back-and-forth movement of the proximal intimal flap through the aortic valve

Eiji Takeuchi , MD, Toshio Abe , MD

Division of Thoracic Surgery
Nagoya University School of Medicine
Nagoya, Japan

To the Editor:

A 61-year-old man had severe precordial chest pain on November 27, 1988. Eleven days later, he was transferred to our institution from our branch hospital with severe aortic regurgitation and pneumonia. At admission, the patient had a productive cough with sputum. Blood pressure was 118/50 mm Hg. A grade 4 diastolic pouring murmur was noted and a harsh murmur was also audible in the third and fourth left intercostal spaces. Chest roentgenogram revealed a widened mediastinum. The cardiothoracic ratio was 0.67, with an overall increase in density over the field of the upper right lung. Two-dimensional echocardiography showed a back-and-forth movement in the intima from a completely free-flowing, round tear. In the systolic phase, the proximal intimal flap ejected into the ascending aorta (Fig. 1). In the diastolic phase, the proximal intimal flap became inverted and swayed back into the outflow tract of the left ventricle through the aortic valve (Fig. 2). Severe aortic regurgitation was observed at this stage. The computed tomographic scan of the thorax revealed a dilated aortic root, but no dissection could be identified.



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  		Fig. 1. Two-dimensional echocardiogram in systolic phase shows proximal intimal flap ejecting into ascending aorta. LV, Left ventricle; LA, left atrium; AO, aorta.

 


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  		Fig. 2. Two-dimensional echocardiogram in diastolic phase shows proximal intimal inverted and swaying back into outflow tract of left ventricle through aortic valve.

 
We performed an emergency operation immediately on the day of admission. No cardiac catheterization was required. At operation, the intimal flap was dissected circumferentially and was cut all the way around at 3 cm above the aortic valve commissure. All three aortic commissures were detached, and the proximal regions in both coronary arteries were found to have been stripped away from the dissected space. The dissection was a DeBakey type II dissection. We chose to perform Cabrol's operation. The patient's postoperative course was uneventful, and he is normally active after the operation.

There are other reports of intima-intimal intussusception of the distal intimal flap.Go Go 1-3 We believe this is a rare case of its kind, with such unusual movement of the proximal intimal flap.

References

  1. Hufnagel CA, Conrad PW. Intimo-intimal intussusception in dissecting aneurysm. Am J Surg 1962;103:727-31. [Medline]
  2. Liotta D, Hallman GL, Milam JD, Cooley DA. Surgical treatment of acute dissecting aneurysm of the ascending aorta. Ann. Thorac Surg 1971;12:582-92. [Medline]
  3. Symbas PN, Kelly TF, Vlasis SE, Drucker MH, Arensberg D. Intimo-intimal intussusception and other unusual manifestations of aortic dissection. J THORAC CARDIOVASC SURG 1980;79:926-32.[Abstract]



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[Abstract] [PDF]

This Article
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