CASE REPORTS Real-Time Three Dimensional Echocardiography in the Postoperative Follow-Up of Type-A Aortic Dissection—A Case Report Denisa Muraru, MD, Luigi P. Badano, MD, Lorenzo Del Mestre, RS, Pasquale Gianfagna, MD, Alessandro Proclemer, MD, and Ugolino Livi, MD, FECTS, Bucharest, Romania; Udine, Italy Aortic dissection is a fearful complication with extremely high mortality in young patients with Marfan syn- drome. Successful aortic emergency surgery increases the life expectancy of these patients, yet it does not prevent disease progression and late complications. Therefore, long-term imaging follow-up of both recon- structed and chronically dissected aortic segments is mandatory. This case report illustrates the potential role of real-time three-dimensional echocardiography as a supplement to conventional postoperative fol- low-up in aortic dissection that provides valuable spatial and functional information. (J Am Soc Echocardiogr 2010;23:682.e1-682.e4.) Keywords: Three-dimensional echocardiography, Aortic dissection, Acute aortic syndrome, Marfan syn- drome, Bicuspid aortic valve, Intimal flap CASE REPORT A 22-year-old man with Marfan syndrome presented with acute chest pain and hemodynamic instability. Urgent preoperative transesopha- geal echocardiography revealed a type-A aortic dissection with di- lated ascending aorta, large pericardial effusion with signs of cardiac tamponade, and a bicuspid aortic valve with mild regurgitation. Surgical intervention consisted of valve-sparing prosthetic replace- ment of the ascending aorta and an endoprosthetic stent graft of the aortic arch. Recovery was uneventful. One month later, transthoracic two-dimensional (2D) echocardi- ography showed normal left and right ventricular size and function and no abnormalities of aortic grafts. The bicuspid aortic valve showed a normal systolic opening with mild eccentric aortic regurgi- tation (Figure 1, Video 1). A real-time three-dimensional echocardio- graphic (RT3DE) en face view of the native aortic valve from its aortic side identified the mechanism of eccentric regurgitation as through a commissural triangular orifice between the two large cusps and a small underdeveloped third cusp (Figure 1). This particular ana- tomic variant was not clearly evident by 2D echocardiographic visu- alization of the aortic cusps from the ventricular side. However, the RT3DE cine loop of valve opening and closing (Video 2) confirmed its functionally bicuspid nature, as identified on 2D echocardiography and transesophageal echocardiography. By slicing and rotating the same aortic root data set, the origins of the left and right coronary ar- teries were also well visualized (Figure 2). An RT3DE subcostal view of the abdominal aorta enabled a thor- ough spatial assessment of the aortic flap. Color Doppler RT3DE imaging of the abdominal aorta identified the true lumen, its dy- namic size relative to the false lumen, and the perfusion of major aortic branches (Video 3). The abdominal extension of the intimal flap was seen distally to the origin of the superior mesenteric artery, ending approximately at the level of the renal arteries, where the use of color Doppler identified a small intimal tear (Video 4). Using electronic cropping tools, cross-sectional images of the ab- dominal aorta were obtained at various levels, and the small distal reentry tear between the two lumens previously identified with color Doppler could be actually appreciated in terms of its size, dy- namic shape, and localization relative to the aortic branches (Figure 3, Video 5). The partial dynamic involvement of the right renal artery origin by the fragmented mobile flap could be also pre- cisely identified (Figure 4, Video 6). DISCUSSION We have presented the case of a patient with Marfan syndrome oper- ated for acute aortic dissection, in which follow-up RT3DE imaging provided important spatial information on flap extension and flow dy- namics in the abdominal aorta, as well as on aortic root anatomy and valvular function. Recent advances in RT3DE imaging allow the opportunity to re- consider the role of cardiac ultrasound for diagnosing and monitoring patients with aortic dissection. Echocardiography enjoys the unique combination of low cost, no radiation exposure, and the ability to pro- vide rapid and safe comprehensive information on anatomic or func- tional abnormalities and flow dynamics at the bedside, which is critically important for the surgeon: localization of entry port and other intimal tears, flow characteristics in both true and false lumens, ventricular function, aortic valve anatomy and regurgitation, cardiac tamponade, and coronary and other aortic branch involvement. In patients with connective tissue disorders, such as those with Marfan syndrome, even after successful surgical reconstruction of the From ‘‘Prof Dr C. C. Iliescu’’ Institute of Cardiovascular Diseases, Bucharest, Romania (D.M.); and the Department of Cardiopulmonary Sciences, University Hospital ‘‘Santa Maria Della Misericordia,’’ Udine, Italy (L.P.B., L.D., P.G., A.P., U.L.). Reprint requests: Luigi P. Badano, University Hospital ‘‘Santa Maria Della Miseri- cordia,’’ Department of Cardiopulmonary Sciences, Piazzale S Maria Della Miser- icordia 15, 33100 Udine, Italy (E-mail: badano.luigi@aoud.sanita.fvg.it). 0894-7317/$36.00 Copyright 2010 by the American Society of Echocardiography. doi:10.1016/j.echo.2009.10.007 682.e1