Aortic root ‘sink down’ caused mitral stenosis after aortic valve replacement: a rare presentation of Bechet’s disease

An abnormal aortic sinus (37 mm) and ascending aorta (42 mm) were detected in a 67-year-old man 9 years ago (Panel A). It showed a progressive widening (53 mm) with moderate aortic regurgitation (Panels B and C) in 2 years of follow-up. Then Aortic valve replacement and ascending aortoplasty were performed (Panels D–F). Intraoperatively, the aortic wall and leaves were thickened, showing fibrous changes but no inflammatory reaction. However, the aortic root began to sink down slightly to left ventricular outflow tract (LVOT) in the first year after surgery, with a normal function of the prosthetic valve and no perivalvular leakage (Panels G–I). A regular follow-up was suggested. In the 6th year after surgery, the patient suddenly suffered from chest tightness, palpitations, and even syncope. Transthoracic echocardiography showed the aortic root sinking was aggravated, which caused LVOT disappearing and severe mitral valve stenosis (Panels J–L, see Supplementary material online, Movies 1–3). Mitral valve replacement and floating Bentall with LVOT reconstruction were performed, and postoperative and 1 monthly follow-up showed normal prosthetic valve function (Panels M–O).