ST-Segment elevation in lead aVR as a manifestation of severe aortic regurgitation: case report and literature review

ST-segment elevation in lead aVR (STE-aVR) with diffuse ST-segment depression (STD) is a high-risk electrocardiographic pattern most often associated with acute coronary syndromes, but it can also occur in severe structural heart disease. Severe aortic regurgitation (AR) is an uncommon but clinically important non-coronary cause. A 51-year-old asymptomatic man was found to have 0.3–0.4 mV STE-aVR with diffuse STD on a routine electrocardiogram. Coronary angiography showed no obstructive disease. Transesophageal echocardiography revised the initial transthoracic suspicion of cusp perforation and demonstrated a Sievers type 1 bicuspid aortic valve with leaflet prolapse and severe eccentric AR. Despite marked left ventricular dilation, the preoperative B-type natriuretic peptide (BNP) level was only 21.7 pg/mL and serial values remained within the reference range. Surgical bioprosthetic aortic valve replacement resulted in substantial resolution of the electrocardiographic abnormalities and marked left ventricular reverse remodeling. A narrative review of published case reports identified acute aortic dissection, infective endocarditis or aortic root abscess, prosthetic valve dysfunction, and sinus of Valsalva aneurysm as recurrent structural contexts associated with this electrocardiographic pattern. Severe AR can produce global subendocardial ischemia through reduced diastolic coronary perfusion and increased left ventricular oxygen demand. In patients with STE-aVR and diffuse STD, the clinical context and early echocardiography are essential for distinguishing acute coronary disease from structural and hemodynamic mimics. Not applicable.