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\begin{document}

\title{Acute aortic regurgitation due to chordae tendineae rupture}



\author[1]{Jason Ali}%
\author[1]{Jonathan Weir-McCall R}%
\author[1]{Choo Ng}%
\affil[1]{Papworth Hospital Theatres Critical Care and Anaesthesia Services}%


\vspace{-1em}



  
  \date{June 08, 2024}


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\begin{abstract}
A 60-year-old male presented with sudden onset chest pain and pulmonary
oedema. Investigation confirmed torrential aortic regurgitation of a
bicuspid valve. At surgery a ruptured chordae tendineae was identified
which had been supporting the left-right cusp commissure with loss of
attachment to the aortic wall. This case demonstrates that chordae
tendineae may be present as a supporting structure of the aortic valve,
and rupture can be a rare cause of torrential aortic regurgitation,
similar in pathogenesis to how it may be associated with acute severe
mitral regurgitation.%
\end{abstract}%



\sloppy


\textbf{Acute aortic regurgitation due to chordae tendineae rupture}

Jason M Ali PhD\textsuperscript{1}, Jonathan R Weir-McCall
PhD\textsuperscript{2}, Choo Y Ng PhD\textsuperscript{1}

Department of Cardiothoracic surgery\textsuperscript{1} and
Radiology\textsuperscript{2}, Royal Papworth Hospital, Cambridge, United
Kingdom

\textbf{Corresponding author}

Jason Ali

Department of Cardiothoracic Surgery

Royal Papworth Hospital

Cambridge

United Kingdom

Email:Jason.ali@nhs.net

Phone/Fax:01223 638000

IRB approval, consent statement and clinical trial registration are not
applicable for this manuscript

Word Count: 505

\textbf{Abstract}

A 60-year-old male presented with sudden onset chest pain and pulmonary
oedema. Investigation confirmed torrential aortic regurgitation of a
bicuspid valve. At surgery a ruptured chordae tendineae was identified
which had been supporting the left-right cusp commissure with loss of
attachment to the aortic wall. This case demonstrates that chordae
tendineae may be present as a supporting structure of the aortic valve,
and rupture can be a rare cause of torrential aortic regurgitation,
similar in pathogenesis to how it may be associated with acute severe
mitral regurgitation.

\textbf{Key Words} : aortic valve regurgitation, chordae tendineae

A 60-year-old male presented with sudden onset severe chest pain and
pulmonary oedema. Echocardiogram confirmed torrential aortic
regurgitation of a bicuspid aortic valve raising the possibility of
infective endocarditis. He did have a dental abscess treated 4-weeks
prior to this admission however, his inflammatory markers were not
elevated, he remained afebrile throughout the admission and repeated
blood cultures were negative. Computed tomography excluded aortic
dissection and significant coronary artery disease.

He was referred to cardiothoracic surgery and proceeded to emergency
aortic valve replacement. No evidence of endocarditis was found on
inspection of the valve. Furthermore, valve culture and histopathology
revealed no evidence of infection. Rather there was a ruptured chordae
tendineae (a fibrous strand) that had been connecting the left and right
commissure to the aortic wall (Figure 1). Its rupture resulted in loss
of attachment of the commissure to the aortic wall, resulting in a flail
leaflet unusually most pronounced at the aortic wall. Careful
retrospective review of the preoperative ECG-gated cardiac CT
demonstrated the pathology (Figure 2).

This case describes ruptured chordae tendineae as a rare cause of acute
aortic regurgitation. Chordae tendineae are more typically implicated in
dysfunction of the mitral valve. However, rarely they may be found as
embryonic remnants supporting aortic valve leaflets and associated with
aortic valve pathology (1). Here, we describe rupture of chordae
tendineae present as a supporting structure of the aortic valve,
resulting in acute loss of aortic leaflet support and subsequent
torrential aortic regurgitation.

\textbf{References}

Abdelaziz MM, Martinelli G, Luckraz H. Chordae Tendineae of the Aortic
Valve. J Card Surg. 2016 May;31(5):328-9

\textbf{Figure 1.} (a) Intraoperative in situ photo and (b) photo of
valve leaflet following resection demonstrating the ruptured chordae
tendineae

\textbf{Figure 2.} On the left there is normal position of the
non-coronary cusp (+), with the flail commissural segment between the
RCC and LCC (white arrowhead) with a resultant large regurgitant orifice
area between the two. On the short axis views in the upper and lower
left ventricular outflow tract, these show the flail right and left
coronary cusps (*), with bridging continuation between these (arrowhead)
with a faint stalk projected into the lumen (arrow).\selectlanguage{english}
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