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Logo of thijTexas Heart Institute JournalSee also Cardiovascular Diseases Journal in PMCSubscribeSubmissionsTHI Journal Website
Tex Heart Inst J. 2007; 34(4): 496–497.
PMCID: PMC2170510

Circumferential Intimal Flap Prolapsing into the Left Ventricle

Raymond F. Stainback, MD, Section Editor
Department of Adult Cardiology, Texas Heart Institute and St. Luke's Episcopal Hospital, 6624 Fannin Street, Suite 2480, Houston, TX 77030

A 54-year-old man with a history of chest pain and dyspnea for 15 days was admitted to our hospital. Diagnostic evaluation, which included transthoracic echocardiography and computed tomographic scanning, revealed an ascending aortic aneurysm (6 cm in diameter), severe aortic valve insufficiency, and possible aortic dissection. The coronary arteries could not be seen, because the catheter could not be placed in their orifices. The patient was taken to the operating room. Intraoperative transesophageal echocardiography revealed an intimal flap in the ascending aorta. The proximal part of the flap was attached to the aortic wall at the level of the coronary ostia, and its distal part was circumferentially free (Fig. 1). The flap was prolapsing into the left ventricular outflow tract through the aortic valve leaflets at every diastole (Fig. 2A) and moving back to the aortic lumen at systole (Fig. 2B). The patient underwent aortic root replacement by means of the Bentall procedure. During surgical exploration, we saw that the dissection involved the commissures and the orifice of the right coronary ostia and that it ended just proximal to the aortic clamp, which did not necessitate the use of hypothermic circulatory arrest (Fig. 3). The patient was discharged from the hospital 6 days after the operation without complication.

figure 27FF1
Fig. 1 Transesophageal echocardiographic appearance of the circumferentially free intimal flap. Real-time motion images are available at
figure 27FF2
Fig. 2 Transesophageal echocardiography shows back-and-forth movement of the intimal flap A) in diastole and B) in systole. Ao = aorta; LV = left ventricle. Real-time motion images are available at
figure 27FF3
Fig. 3 Intraoperative view of the aortic root. The large arrow shows the intimal flap, and the small arrow shows the circumferential mural aorta. F = false lumen; T = true lumen


The mechanisms of aortic valve insufficiency in aortic dissection have been well described.1 Diastolic prolapse with back-and-forth movement of the intimal flap is a rare cause of aortic insufficiency, which to our knowledge has been reported in only 5 patients other than ours.1,2 In our patient, the dissection of the commissures and coronary ostia, together with enlargement of the sinuses of Valsalva, required aortic root replacement.

We can speculate that, because of the circumferential ending of the intimal flap, the dissection did not propagate distally. Therefore, it was likely a DeBakey type II dissection, as in a similar case reported previously.1

Supplementary Material

Video for Fig. 1:


Address for reprints: Anil Apaydin, MD, Department of Cardiovascular Surgery, Ege University Medical School, Izmir 35100, Turkey. E-mail: rt.ude.ege@nidyapa.lina


1. Nohara H, Shida T, Mukohara N, Nagariki K, Matsumori M, Ogawa K. Aortic regurgitation secondary to back-and-forth intimal flap movement of acute type A dissection. Ann Thorac Cardiovasc Surg 2004;10:54–6. [PubMed]
2. Takeuchi E, Abe T. A back-and-forth movement of proximal intimal flap through the aortic valve. J Thorac Cardiovasc Surg 1994;107:1539–40. [PubMed]

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