{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T17:46:09Z","timestamp":1789062369604,"version":"build-2803163510"},"reference-count":11,"publisher":"Oxford University Press (OUP)","issue":"9","license":[{"start":{"date-parts":[[2023,9,11]],"date-time":"2023-09-11T00:00:00Z","timestamp":1694390400000},"content-version":"vor","delay-in-days":10,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,9,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Bicuspid aortic valve (BAV) with displacement of the attachment of the conjoined aortic leaflet and fibrous strands is a rare cardiac malformation. We report a case of BAV that presented as acute massive aortic regurgitation during cardiopulmonary bypass for a planned non-valve\u2013related procedure and was successfully treated by emergency aortic valve replacement.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Case summary<\/jats:title>\n                  <jats:p>A 70-year-old man with triple vessel coronary disease and severe left ventricular systolic dysfunction underwent coronary bypass grafting and graft replacement of the ascending aorta. Acute aortic regurgitation occurred during ventricular fibrillation and after de-clamping of the aortic graft. Intra-operative findings included a fused BAV (right\u2013left cusp fusion), very asymmetrical leaflet (commissure angle of the non-fused leaflet 135\u00b0), three aortic sinuses, and conjoined leaflets originating from the myocardium in the inter-ventricular septum. The aortic leaflets were resected and replaced with a prosthetic aortic valve at the attachment site of the conjoined leaflets. Post-operatively, no peri-valvular leaks were observed, and left ventricular function was improved.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Discussion<\/jats:title>\n                  <jats:p>Intra-operative acute massive aortic regurgitation may be caused by a morphologically abnormal aortic leaflet and root complex in patients with a BAV. The dilated aortic root, asymmetrical leaflet, and abnormal aortic leaflet insertion, with thick septal myocardium of the coronary aortic sinus, might have caused unstable leaflet co-aptation, leading to deformation of the aortic leaflets influenced by the change in myocardial tone and intra-operative change in the sinotubular junction. Familiarity with the classification of congenital BAV, and the anatomy of the normal and abnormal aortic root complex, is important.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/ehjcr\/ytad459","type":"journal-article","created":{"date-parts":[[2023,9,12]],"date-time":"2023-09-12T03:05:39Z","timestamp":1694487939000},"source":"Crossref","is-referenced-by-count":1,"title":["Acute severe aortic insufficiency during cardiopulmonary bypass in a bicuspid aortic valve with unrecognized annular displacement and fibrous strands: a case report"],"prefix":"10.1093","volume":"7","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5776-1877","authenticated-orcid":false,"given":"Tetsuya","family":"Saito","sequence":"first","affiliation":[{"name":"Department of Cardiovascular Surgery, National Hospital Organization Osaka National Hospital , 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006 , Japan"},{"name":"Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine , 2-2 Yamadaoka, Suita, Osaka 565-0871 , Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masashi","family":"Kawamura","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine , 2-2 Yamadaoka, Suita, Osaka 565-0871 , Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Takashi","family":"Murakami","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, National Hospital Organization Osaka National Hospital , 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006 , Japan"},{"name":"Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine , 2-2 Yamadaoka, Suita, Osaka 565-0871 , Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masayuki","family":"Sakaki","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Surgery, National Hospital Organization Osaka National Hospital , 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006 , Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2023,9,11]]},"reference":[{"key":"2023092216410186300_ytad459-B1","doi-asserted-by":"crossref","first-page":"361","DOI":"10.1378\/chest.72.3.361","article-title":"Spontaneous rupture of bicuspid aortic valve. An unusual cause of aortic insufficiency","volume":"72","author":"Becker","year":"1997","journal-title":"Chest"},{"key":"2023092216410186300_ytad459-B2","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1007\/s11748-010-0722-8","article-title":"Aortic regurgitation caused by rupture of the abnormal fibrous band between the aortic valve and aortic wall","volume":"59","author":"Minami","year":"2011","journal-title":"Gen Thorac Cardiovasc Surg"},{"key":"2023092216410186300_ytad459-B3","doi-asserted-by":"crossref","first-page":"843","DOI":"10.1067\/mtc.2002.124296","article-title":"Aortic regurgitation caused by rupture of a well-balanced fibrous strand suspending a degenerative tricuspid aortic valve","volume":"124","author":"Nakajima","year":"2002","journal-title":"J Thorac Cardiovasc Surg"},{"key":"2023092216410186300_ytad459-B4","doi-asserted-by":"crossref","first-page":"448","DOI":"10.1093\/ejcts\/ezab038","article-title":"International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes","volume":"60","author":"Michelena","year":"2021","journal-title":"Eur J Cardiothorac Surg"},{"key":"2023092216410186300_ytad459-B5","doi-asserted-by":"crossref","first-page":"351","DOI":"10.1093\/ejcts\/ezz033","article-title":"Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification","volume":"56","author":"de Kerchove","year":"2019","journal-title":"Eur J Cardiothorac Surg"},{"key":"2023092216410186300_ytad459-B6","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1053\/j.semtcvs.2020.01.001","article-title":"Living anatomy of the ventricular myocardial crescents supporting the coronary aortic sinuses","volume":"32","author":"Toh","year":"2020","journal-title":"Semin Thorac Cardiovascular Surg"},{"key":"2023092216410186300_ytad459-B7","doi-asserted-by":"crossref","first-page":"425","DOI":"10.1016\/j.jtcvs.2014.09.042","article-title":"Surgical anatomy of the aortic root: implication for valve-sparing reimplantation and aortic annuloplasty","volume":"149","author":"De Kerchove","year":"2015","journal-title":"J Thorac Cardiovasc Surg"},{"key":"2023092216410186300_ytad459-B8","first-page":"57","article-title":"Severe aortic regurgitation resulting from a downward displacement of anterior aortic annulus and fibrous strands in the bicuspid aortic valve","volume":"16","author":"Mishima","year":"2010","journal-title":"Ann Thorac Cardiovasc Surg"},{"key":"2023092216410186300_ytad459-B9","first-page":"177","article-title":"A rare case of downward deformity of right coronary valve","volume":"17","author":"Gao","year":"2001","journal-title":"Chin J Thorac Cardiovasc Surg"},{"key":"2023092216410186300_ytad459-B10","doi-asserted-by":"crossref","first-page":"308","DOI":"10.1016\/S0022-5223(19)35914-8","article-title":"Downward displacement of aortic anulus leading to aortic and mitral regurgitation","volume":"92","author":"Hou","year":"1986","journal-title":"J Thorac Cardiovasc Surg"},{"key":"2023092216410186300_ytad459-B11","first-page":"707","article-title":"Downward displacement of the aortic annulus: case report and literature review","volume":"24","author":"Mo","year":"2015","journal-title":"J Heart Valve Dis"}],"container-title":["European Heart Journal - 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