INTRODUCTION
The prevalence of valvular heart diseases (VHD) is estimated to be 2.5%
in developed countries (1). Among VHD, aortic regurgitation (AR) is
reported to be the third most common form, following mitral
regurgitation (MR) and aortic stenosis (AS) (2). The prevalence of VHD
increases especially in patients over 65 years of age because of the
predominance of degenerative etiologies (1). Several surveys have been
performed to clarify the etiologies of AR so far. Roberts et al.
examined 268 patients who had isolated aortic valve (AV) replacement
(AVR) for pure AR and concluded that the causes of AR were diverse and
the most common category was “cause unclear” in their study (3). In
the Euro Heart Survey on VHD, degenerative tricuspid and bicuspid AR
were the most common etiologies, accounting for approximately two-thirds
of the underlying etiology of AR in the Euro Heart Survey on VHD
(4) (5).
In detail, degenerative origin of AR accounted for approximately half
(50.3%) and rheumatic AR was present in 15.2%. In addition, Braun et
al. reported that RA and other connective tissue diseases can cause
valvular disease including AR (6). While AVR has been an established
surgical definitive therapy for the treatment of AR, aortic
valvuloplasty (AVP) has also been acknowledged gradually as another
surgical option for AR (7). Although AVP is not so prevailed as mitral
valvuloplasty, both plasty procedures have more advantages such as
freedom from anticoagulant therapy. It is essential to conduct precise
anatomical assessment preoperatively for a successful valvuloplasty and
for the prevention of recurrence of significant regurgitation (8).
Recent advancement in echocardiography enables to detect more detailed
abnormal morphology of aortic cusps accurately. Cusp bending of aortic
valve has been detected more commonly with AR on transesophageal
echocardiography (TEE) examination, which is observed as a fibrous band
on a cusp (Figure 1, 2, 3, 4) (9) (10) (11). Nevertheless, the
prevalence of cusp bending and its clinical characteristics remain to be
clarified in pure AR patients. Therefore, the aim of this study was to
thoroughly examine the etiologies of AR through observing aortic valve
morphology by use of TEE images.