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A 44-year-old woman with long-standing rheumatoid arthritis presented with exertional breathlessness since the last 3 months; cardiovascular examination revealed a decrescendo diastolic murmur along the left upper sternal border. A transthoracic and transesophageal echocardiogram revealed normal sized left ventricle, normal ventricular systolic function and a quadricuspid aortic valve (QAV) with mild aortic regurgitation (figure 1A,B; supplementary video 1). A 3D echocardiographic reconstruction was performed which clearly delineated the anatomy of the quadricupid aortic valve with four equal sized cusps forming the characteristic ‘X’ configuration during diastole (figure 1C) and opening fully during systole (figure 1D; supplementary video 2). Mild central leaflet tip mal-coaptation with AR was confirmed.
Although previously reported at autopsy or during cardiac surgery, the advent of sophisticated echocardiography techniques has resulted in cases of QAV being reported more frequently.1 Seven anatomic variations of QAV are described, with the type having four equal cusps (type A) being the most frequent, as observed in our case.2 While aortic regurgitation is common due to cuspal mal-coaptation, aortic stenosis is rare.
Associations of QAV include hypertrophic cardiomyopathy, atrial septal defect, patent ductus arteriosus, ventricular septal defects, bicuspid pulmonary valve and congenital coronary anomalies. Rheumatoid arthritis often leads to aortic regurgitation (AR) due to aortitis with dilated aortic annulus, aortic valve prolapse or inflammatory involvement of the valve itself.3 To the best of our knowledge, presence of QAV leading to AR has not been reported before in rheumatoid arthritis.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online video 1
- Data supplement 2 - Online video 2
Footnotes
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Contributors All the authors have contributed to the drafting and preparing of the manuscript. All the authors have read and approved the manuscript before submission.
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Competing interests None.
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Patient consent Obtained.
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Provenance and peer review Not commissioned; internally peer reviewed.