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doi:10.1093/eurheartj/ehs115
Online publish-ahead-of-print 9 July 2012

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Balloon-like intimal flap in the left ventricle
Mehmet Sukru Efem, Demet Ozkaramanli Gur*, and Emel Ersoz
Tekirdag State Hospital, Tekirdag, Turkey

* Corresponding author. Tel: +90 5302820997, Fax: +90 3922253299, Email: dozkarm@yahoo.com

A 61-year-old man with a prior history of
hypertension presented to the emergency department with loss of counsciousness and right hemiplegia. His
physical examination revealed low
blood pressure (80/50 mmHg on both
arms) and normal sinus rhythm on electrocardiogram. Diffusion magnetic resonance imaging showed a relatively large
infarct in the left parietal hemisphere.
The cardiovascular examination was unremarkable. The transthoracic echocardiography revealed a dilated proximal
aorta of 5.6 cm, a large balloon-like
intimal flap prolapsing into the left ventricle in diastole, and severe aortic
regurgitation contained by the flap. The
left ventricle was hypertrophic with no
wall motion abnormality. Approximately
5– 10% of the patients with aortic dissection have accompanying ischaemic stroke
through the occlusion of cerebral vessels by the extension of dissection to carotid arteries, by the closure of vessels by the intimal flap,
or by distal embolization of the thrombus formed in the false lumen. Diastolic prolapse with back-and-forth movement of the intimal
flap is a rare cause of aortic insufficiency in aortic dissection and is a result of total or near-total circumferential tear. To our knowledge, aortic regurgitant flow contained by the intimal falp is the first to be reported and had caused low cardiac output syndrome in
our patient. The patient was operated with the Bentall procedure and intraoperative findings confirmed that the patient had Stanford
type A dissection with a mobile flap and thrombus in the false lumen. Distal embolization was the possible cause of stroke. Routine
echocardiograpic examination which revealed aortic dissection is advisable in every patient with cerebrovascular accident in the
thrombolytic era.
Panel: Transthoracic echocardiographic views demonstrating aortic dissection, intimal flap, and the regurgitant flow contained by the
flap.
Supplementary material is available at European Heart Journal online.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2012. For permissions please email: journals.permissions@oup.com

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