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Objectives This report calls attention to an unappreciated cause of both acute and chronic aortic regurgitation (AR). Background Although stenosis develops in most patients with a congenitally bicuspid aortic valve (BAV), in others with this anomaly, pure AR (no element of stenosis) develops, some in the absence of infection or other clear etiology. Methods We describe 5 men who underwent aortic valve replacement for pure AR associated with a BAV containing an anomalous cord attaching the raphe of the conjoined cusp near its free margin to the wall of the ascending aorta cephalad to the sinotubular junction. Results Three of these 5 patients had a history of progressive dyspnea, and the anomalous cord, which was intact at operation, appeared to cause chronic AR by preventing proper coaptation of the 2 aortic valve cusps. The other 2 patients heard a “pop” during physical exertion and immediately became dyspneic, and at operation, the anomalous cord was found to have ruptured. Prolapse of the conjoined aortic valve cusp toward the left ventricular cavity resulted in severe acute AR. Conclusions This variant of the purely regurgitant BAV may cause either chronic AR (when the anomalous cord does not rupture) or acute severe AR (when the cord ruptures).

Functional mitral regurgitation (MR) occurs most often in patients with heart failure (HF) and is associated with an adverse prognosis. Recently, B-type natriuretic peptide (BNP) has been validated as a marker of cardiac function and prognosis. We sought to assess the relation between functional MR and BNP levels in patients with HF, and hypothesized that MR is associated with higher BNP levels. In all, 201 patients admitted with the diagnosis of HF had a transthoracic echocardiogram and measurement of BNP levels within 48 hours. MR was graded as none/trace, mild, moderate, or severe using recently published guidelines of the American Society of Echocardiography. BNP was measured by a commercially available instrument (Biosite). The relation of MR to BNP was assessed using multivariable linear regression methods with a Tobin estimation to account for the truncation of BNP values at an upper limit of 1,300 pg/ml. Mean age of the patients was 67 ± 11 years. The median BNP level was 826 pg/ml. The etiology of HF was predominantly diastolic in 64 patients (32%); 137 patients (68%) had significant left ventricular (LV) systolic dysfunction. Mean LV ejection fraction was 37 ± 17%. MR was present in 112 patients (56%). After adjusting for clinical, hemodynamic, and echocardiographic variables, only LV ejection fraction (p = 0.016) and moderate or severe MR (p = 0.023) were significantly associated with BNP. When MR was grouped as any MR versus no MR, only LV ejection fraction (p = 0.017) and any degree of MR (p = 0.029) were significantly associated with BNP.

Qualitative grading of mitral regurgitation severity has significant pitfalls secondary to hemodynamic variables, sonographic technique, blood pool entrainment, and the Coanda effect. Volumetric and proximal isovelocity surface area methods can be used to quantitate regurgitant orifice area, regurgitant volume, and regurgitant fraction, but have several limitations and can pose technical challenges. The vena contracta width method provides a rapid and accurate quantitative assessment of mitral regurgitation severity, but is clinically underused. This article is intended to generate an understanding of the flow mechanics of the vena contracta and the sonographic technique required to provide consistent and accurate measurements of vena contracta width in patients with mitral regurgitation.

In adult patients with atrial septal defects (ASDs), right ventricular (RV) cavity size may return to normal after operative closure. This study demonstrated improved RV volumes and right atrial areas in 20 adult patients after successful transcatheter closure of large ASDs. RV volumes decreased by 22%, 30%, and 41% at 1 day, 1 month, and 6 months, respectively, after the procedure. Right atrial areas decreased by 5%, 23%, and 26%, respectively, over the same time.

A 60-year-old man whose operatively excised stenotic and regurgitant aortic valve weighed nearly 15 g, approximately 30 times the normal weight in an adult, is described. To the investigators' knowledge, this is the heaviest aortic valve ever encountered in a human being.