Sudden deterioration of aortic regurgitation due to rupture of a raphal cord on the conjoined cusp

A 57-year-old man was admitted to hospital for acute myocardial infarction associated with mild aortic regurgitation, which was successfully treated b y intracoronary thrombolysis. Twenty-four days later, he suffered from anot her chest pain attack without any electrocardiographic ST-T changes. The co ronary angiogram did not show any significant lesions, but the aortic root angiogram showed massive aortic regurgitation. Surgery revealed a bicuspid aortic valve with a conjoined cusp that had a fenestrated raphe torn away f rom the aortic wall and prolapsing into the left ventricle. The aortic valv e was successfully replaced with a St Jude Medical mechanical valve prosthe sis. The pathological significance of the intact raphal cord and the ruptur e remains an unsolved problem. This is the first reported case in which an increase of aortic regurgitation due to a ruptured raphal cord supporting t he conjoined cusp was confirmed by a serial root angiogram.