Severe Eccentric Aortic Regurgitation Secondary to Noncoronary Cusp Fibroelastoma Presenting with Dyspnea and Orthopnea Despite Negative Prior Cardiac Workup

Document Type

Conference Proceeding

Publication Date

5-15-2026

Publication Title

Am J Respir Crit Care Med

Keywords

General & Internal Medicine, Respiratory System

Abstract

Introduction: Severe eccentric aortic regurgitation (AR) can present insidiously and evade detection on routine cardiac evaluations. Noninvasive studies, including transthoracic echocardiography (TTE) and stress testing, may appear normal despite clinically significant valvular disease. We report a case of severe eccentric AR due to a fibroelastoma on the noncoronary cusp, which contributed to cusp distortion, in a patient with progressive dyspnea and orthopnea. Case Presentation: A 71-year-old woman with hypertension, chronic kidney disease stage IV, type 2 diabetes mellitus, hyperlipidemia, hypothyroidism post-thyroidectomy, and obstructive sleep apnea presented with worsening dyspnea, orthopnea, and bilateral lower extremity edema. Prior workup was largely unremarkable: TTE 09/07/2025: Normal left and right ventricular size and systolic function (EF 55-60%), mildly thickened mitral and aortic valve leaflets with normal cusp separation. Cardiac catheterization 08/2025: Nonobstructive coronary artery disease (40-50% distal left anterior descending stenosis; 80-90% diagonal 2 ostial stenosis). Lexiscan 12/2024: Low risk for stress-induced ischemia. Despite these findings, she demonstrated wide pulse pressure (112/56 mmHg) with bounding pulses and persistent symptoms. Transesophageal echocardiogram 10/20/2025: Trileaflet aortic valve with mild bowing of the noncoronary cusp into the left ventricular outflow tract, resulting in mild cusp coaptation and severe eccentric AR. A small filamentous mass (fibroelastoma) at the base of the noncoronary cusp was identified, likely contributing to cusp distortion; the appearance was not suggestive of vegetation. Mild mitral regurgitation and preserved EF (50-60%) were also observed. The patient underwent surgical aortic valve replacement and single-vessel coronary artery bypass grafting. Postoperatively, she was managed in the cardiovascular ICU with standard antihypertensives, atrial fibrillation prophylaxis, diabetes management, thyroid hormone replacement, and dual antiplatelet therapy. She demonstrated symptomatic improvement and hemodynamic stabilization. Discussion: This case emphasizes that severe eccentric AR may be underestimated by standard TTE, stress testing, or cardiac catheterization, particularly when an eccentric jet or structural abnormality such as a fibroelastoma is present. The fibroelastoma contributed to cusp distortion, exacerbating regurgitation severity. Transesophageal echocardiography is critical for accurate assessment when clinical suspicion persists. Recognition of wide pulse pressure and bounding pulses is essential for timely diagnosis. Conclusion: Persistent dyspnea and orthopnea despite negative prior cardiac evaluations warrant advanced imaging. Eccentric AR caused or worsened by cusp masses, such as fibroelastoma, should be considered, as early detection and surgical intervention improve outcomes.

Volume

212

First Page

1

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