case_images: PMC4900319_01
case_images: (a) Three-dimensional transesophageal echocardiography (3D TEE) showing dissection flap (red arrow) in ascending aorta during systole. (b) 3D TEE showing dissection flap (red arrow) prolapsing into aortic valve during diastole causing severe aortic regurgitation
case_images: ACA-18-83-g001.jpg
case_images: PMC4900319_01_ACA-18-83-g001.jpg
case_images: F1
case_images: TEE also demonstrated severe aortic regurgitation with better visualization of the underlying pathology. 3D TEE revealed that the aortic regurgitation was caused by a tear in the intimal flap that prolapsed into the aortic valve preventing full closure of the valve despite normal leaflet morphology [Figure 1]. These findings were discussed with the surgeon who opted to resuspend the aortic valve as opposed to replacing it, in addition to replacing the ascending aorta and the hemiarch. The patient had an uneventful postoperative course and was discharged 1-week after surgery.
case_images: PMC4900319_02
case_images: Dissection flap (thin red arrow) originating just around the right coronary artery (RCA) orifice (thick red arrow). Flap intermittently occluding RCA flow but not involving the orifice
case_images: ACA-18-83-g002.jpg
case_images: PMC4900319_02_ACA-18-83-g002.jpg
case_images: F2
case_images: TEE demonstrated an intact RCA orifice that was not involved in the dissection, however, further visualization of the dissection flap showed the flap covering and occluding the RCA orifice during diastole [Figure 2]. The surgeon noted perforation of the aortic root just at the level of the RCA.
case_images: PMC4900319_03
case_images: Right coronary artery orifice (white arrow) within the false lumen
case_images: ACA-18-83-g003.jpg
case_images: PMC4900319_03_ACA-18-83-g003.jpg
case_images: F3
case_images: In addition, the right coronary orifice was clearly visualized to be within the false lumen [Figure 3].