Iatrogenic aortic valve fenestration rupture following coronary angiography: a case report

Abstract

Background: Aortic valve fenestration (AVF) is a relatively common anatomical variation, while its rupture is a rare cause of aortic regurgitation (AR), especially following coronary angiography. This case report highlights the importance of echocardiographic evaluation and multidisciplinary discussion for the differential diagnosis of fibroelastoma or endocarditis.

Case summary: A 66-year-old man presented with acute shortness of breath following coronary angiography for an inferior ST-elevation myocardial infarction. Echocardiography revealed severe aortic regurgitation associated with a filamentous mobile structure on the non-coronary cusp. A multidisciplinary discussion was conducted to determine the cause of the AR, leading to the patient undergoing aortic valve replacement. A gross inspection of the valve confirmed AVF rupture.

Conclusion: Iatrogenic AVF rupture following coronary angiography is an exceptionally rare complication. Thorough echocardiographic evaluation plays a significant role in differentiating AVF rupture from other valve pathologies, such as fibroelastoma, Lambl's excrescence, or endocarditis. Echocardiographic features, including a very thin, linear, and flail-like mobile lesion, the paracommissural location, frequent involvement of the non-coronary cusp, and an eccentric jet of the AR, are suggestive of AVF rupture. While medical history and clinical examination contribute to the diagnostic process, definitive diagnosis relies on surgery and anatomopathology.

Keywords: Aortic regurgitation; Aortic valve replacement; Cardiac tumours; Case report; Coronary angiography; Echocardiography.

Figure 1

Schematic transversal view of aortic valve with fenestrations (arrows).

Figure 2

Perioperative transoesophageal echocardiography mid-oesophageal aortic valve short (A and B) and long axis (C and D) view showing a flail-like lesion suggestive of aortic valve fenestration rupture (arrows); and severe aortic regurgitation with eccentric jet in mid-oesophageal long axis view with Doppler mode (E).

Figure 3

Perioperative surgical photographs after aortotomy (A) and after excision of the aortic valve (B) showing the laceration of the free edge of the non-coronary cusp (arrows).