Acute Aortic Dissection with Intimal Layer Prolapse into the Left Ventricle

34-year-old male presented with acute onset ofsearing chest pain and was preoperatively diagnosedwith a Type A dissection limited to the ascendingaorta and arch. His preoperative troponin levels werenot elevated. The patient was scheduled for urgentrepairofaTypeAascendingaortaandtransversearchdissection under hypothermic circulatory arrest usingselective antegrade cerebral perfusion. The intraopera-tive transesophageal echocardiogram (TEE) examina-tion was performed using the Philips 5500 ultrasoundmachine with a Philips OmniPlane III ultrasoundprobe.Multiple views of the left ventricle (LV) revealed alarge intimal flap, prolapsing several centimeters intothe LV outflow tract during diastole. Severe (4)aortic insufficiency (AI) was diagnosed with colorflow Doppler, but regurgitant flow was containedwithin the prolapsing, intimal “sock.” No evidence ofregurgitantflowbeyondtheprolapsedintimallayerinthe LV outflow tract was demonstrated (Fig. 1). TheLV was dilated with moderate, global hypokinesis. Noregional wall motion abnormalities were noted andthe ejection fraction was estimated at 40%.Careful comparison of the aortic valve (AV) inmidesophageal (ME) long axis, and ME AV short axis(SAX) views suggested functional, bicuspid leafletexcursion, mild thickening, and no significant leafletcalcification or stenosis. The aorta was 2.6 cm at theAV annulus, 4.8 cm at the sinus of Valsalva, 7.2 cm atthe sino-tubular junction, and larger than 7.5 cm in thevisualized portion of the ascending aorta.Surgical inspection confirmed the diagnosis of bi-cuspid AV. The left/right coronary cusp was partiallyfused with a congenital cleft from the midportion tothe free leaflet edge. The intima of the sinus ofValsalva was 80% circumferentially torn, with ananchor point surrounding the left main coronary ostia.The surgeon performed a valve-sparing aortic rootreplacement using the David V re-implantation tech-nique with 32-mm Gelweave Valsalva graft (VascutekUSA Inc). The valve annulus was reduced in circum-ference with an aortic valvuloplasty, and the AV cuspcleft was closed with interrupted sutures. A buttonre-implantation of the left coronary ostia into the graftwas possible. The right coronary ostium was partiallydisrupted, and a saphenous vein graft bypass wasperformed.The patient was successfully weaned after 304 minof cardiopulmonary bypass, including 27 min of deephypothermic circulatory arrest. Moderate inotropicsupport was required. The cardiac function was de-pressed from baseline to an estimated 30% ejectionfraction. No new-onset regional wall motion abnor-malities were demonstrated.The postcardiopulmonary bypass TEE examinationrevealed a functional bicuspid valve with good excur-sion of leaflets and no subsequent aortic insufficiency.Planimetry of the effective orifice area measured 2.10cm