|Year : 2017 | Volume
| Issue : 1 | Page : 38-41
Transcatheter closure of Type I ruptured right sinus of Valsalva aneurysm
Sheshagiri Rao Damara1, Ramachandra Barik2, Sivaprasad Akula1
1 Department of Cardiology, AIIMS, Bhubaneswar, Odisha, India
2 Department of Cardiology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
|Date of Web Publication||10-Mar-2017|
Department of Cardiology, AIIMS, Sijua, Patrapada, Bhubaneswar - 751 019, Odisha
Source of Support: None, Conflict of Interest: None
Transcatheter closure (TCC) of ruptured sinus of Valsalva aneurysm (RSOVA) is as an alternative strategy to surgery. Its location, size, and relation to neighboring structures decide treatment plan. We present a 17-year-old young man who presented with the New York Heart Association II shortness of breath for last 2 months. Two-dimensional echocardiography revealed RSOVA of right coronary sinus into right ventricular outflow tract, Seller's II aortic valve regurgitation, and small subaortic ventricular septal defect. The echo estimated size of the defect was 9 mm on the aortic side. Echo was complemented by computed tomography. The defect was crossed retrogradely and was plugged antegradely using an Amplatzer duct occluder (ADO). At 1 year follow-up, ADO was across RSOVA without any residual shunt. TCC of RSOVA is feasible and effective with the support of multiple imaging methods.
Keywords: Amplatzer duct occluder, sinus of Valsalva aneurysms, transcatheter closure
|How to cite this article:|
Damara SR, Barik R, Akula S. Transcatheter closure of Type I ruptured right sinus of Valsalva aneurysm. Nig J Cardiol 2017;14:38-41
| Introduction|| |
The aneurysm of sinus of Valsalva develops in a weak area between the aortic annulus fibrosa and media due to the failure of the distal bulbar septum to fuse with the truncal ridges. Therefore, whether congenital or acquired, these aneurysms are in proximity to the aortic valve and subaortic ventricular septal defect (VSD). Surgery has good reputation having a <4% mortality rate and good long-term results. Transcatheter closure (TCC) of ruptured sinus of Valsalva aneurysm (RSOVA) appears to be a reasonable alternative., A thorough workup of location, size, proximity to neighboring structures, complications, associated congenital anomalies, and acquired causes if any are mandatory to rule in TCC , to avoid unusual complications such as residual shunt, device embolization, aortic regurgitation (AR), hemolysis, and complete heart block.,,
| Case Report|| |
A 17-year-old male presented with progressive dyspnea for a period of 2 months. On examination, blood pressure was 158/60 mmHg, and superficial harsh continuous IV/VI murmur with cat purring quality was heard at left parasternal area in the third and fourth intercostal space. Blood culture was sterile. Chest X-ray showed cardiomegaly [Figure 1]a. Twelve-lead electrocardiogram revealed left ventricular (LV) volume overload [Figure 1]b. Transthoracic echocardiogram (TTE) revealed Type I right RSOVA into right ventricular outflow tract (RVOT), small subaortic VSD, and mild AR due to prolapse of the right coronary cusp [Figure 2] and Videos 1, 2]. There was no RVOT obstruction. All cardiac chambers were dilated; LV ejection fraction was 53% (LV size: 57 mm × 41 mm). Right ventricular systolic pressure by tricuspid regurgitation jet velocity was 48 mmHg. Ultrasound of the abdomen showed abdominal situs and congestive hepatomegaly. The size of RSOVA from aortic side was 9 mm and length of windsock of 2.2 cm [Figure 2] in the transesophageal echo (TEE). The patient was stabilized medically. The patient was not wiling for surgical closure. Computed tomography (CT) with three-dimensional (3D) reconstruction revealed the size of RSOVA on aortic side and in the RVOT were 10 mm and 5.7 mm, respectively. The distance of RSOVA from aortic valve and right coronary artery were 22 mm and 24 mm, respectively. On cardiac catheterization, the room air saturations in % were superior venacava (SVC): 58.5; inferior venacava (IVC): 67; MVO2: 63.3; right atrium (RA): 64.2; right ventricle (RV): 67; pulmonary artery (PA): 84; and femoral artery (FA): 97 in %. Pressures in data showed FA: 170/64/100; left ventricle (LV): 150/8; pulmonary artery capillary wedge pressure (PCWP): 7; pulmonary artery pressure (PAP): 40/3; and RV: 55/4 in mmHg. LV and aortic root angiogram showed normal coronaries arteries, small subaortic VSD, RSOVA Type I (Sakakibara and Konno classification), and less than Seller's Grade II AR [Figure 3]. Transcatheter device closure was performed under local anesthesia. Right femoral 6Fr arterial access and 7F venous access were obtained. Using 6F pigtail catheter through right femoral artery, aortic root angiogram was performed in the left anterior oblique and right anterior oblique 40°–45°, respectively, to profile RSOVA before closure. A communication between right aortic sinus and RVOT of 10 mm and trivial AR were visualized. The defect was crossed from right femoral artery using 5F Judkin's right coronary catheter (Cordis, Miami Lakes, FL, USA) and hydrophilic guide wire (Terumo Co-operation, Tokyo, Japan). The Terumo guide wire was snared from pulmonary artery using an indigenously made snare (5Fr right Judkin's catheter and folded exchange length percutaneous transluminal coronary angioplasty guide wire) [Figure 4]a. Initial wire was replaced with exchange length 0.035 inch × 260 cm Amplatzer extra stiff guide wire from right femoral vein. Over the loop from right femoral vein, 8F Cook sheath (Cook Medical, Bloomington, IN) was placed across RSOVA defect [Figure 4]b. A 10/12 Amplatzer patent ductus arteriosus occluder was used to plug the RSOVA. After confirmation by TTE and aortic root angiogram, device was deployed successfully [Figure 4]c. On the 3rd day, TTE [Figure 4] and TEE [Videos 3 and 4] confirmed stable position of Amplatzer duct occluder (ADO) across the RSOVA without no residual shunt, mild AR, and small subaortic VSD [Video 4]. He was discharged with a daily dose oral aspirin of 150 mg and infective endocarditis prophylaxis. At 1-year follow-up, the patient had mild TTE revealed stable position of device without worsening of AR [Figure 5].
|Figure 1: Chest X-ray suggestive of cardiothoracic ratio of 0.6, left ventricular apex and pulmonary plethora (a), and 12-lead electrocardiogram revealed volume overload type of left ventricular hypertrophy (b)|
Click here to view
|Figure 2: Preoperative transesophageal echo image of ruptured sinus of Valsalva aneurysm to the right ventricular outflow tract in parasternal short axis view showing a defect of size 9 mm on the side right coronary sinus|
Click here to view
|Figure 3: Computed tomography of aortic root with three-dimensional reconstruction was congruent with transthoracic echocardiogram and transesophageal echo (Label upper (a) and lower (b))|
Click here to view
|Figure 4: A fluoroscopic images show snaring of exchange length wire from pulmonary artery using indigenous snare from right femoral vein to complete femur-femoral arteriovenous loop (a). An 8Fr dedicated sheath has been maneuver from venous approach (b). Right anterior oblique view shows proper positioning Amplatzer duct occluder device plugging ruptured sinus of Valsalva aneurysm without impingement on aortic valve (c) and transesophageal echo after 3 months shows Amplatzer duct occluder in situ looks apparently protruding into right ventricular outflow tract without right ventricular outflow tract obstruction or residual leak (d)|
Click here to view
|Figure 5: Transesophageal echo shows Amplatzer duct occluder in situ across ruptured sinus of Valsalva aneurysm in long axis view (120°)|
Click here to view
| Discussion|| |
Our patient had Sakakibara Type I RSOVA  with mild AR and small subaortic VSD on echocardiogram and aortic root angiogram. We had no 3D TEE. Therefore, we opted for CT aortic root angiogram for detail which is must for TCC. A detail 3D anatomical knowledge of the RSOVA and surrounding structures, including coronary artery, is necessary before intervention. Although TTE is very useful to profile the anatomy, one may not always appreciate all the adjacent defects of RSOVA on echocardiogram. Cardiac chest CT with 3D angiographic view is very helpful for comprehensive aortic root evaluation. In our case, we observed each additional imaging modality adds incremental information which the confidence of operator by removing limitation of one imaging method over other. It does not mean that each and every patient would need all imaging modalities preceding intervention, rather we suggest whenever needed, additional imaging support which significantly complements the details of missing anatomy.
| Conclusion|| |
Percutaneous closure of ruptured sinus of Valsalva is easier when it's etiology, location, size, distant from coronary artery ostium, distance from aortic valve, neighboring structures, associated congenital defects, and complications are properly evaluated by multiple imaging methods before selection of a case for device closure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shah RP, Ding ZP, Ng AS, Quek SS. A ten-year review of ruptured sinus of Valsalva: Clinico-pathological and echo-Doppler features. Singapore Med J 2001;42:473-6.
Takach TJ, Reul GJ, Duncan JM, Cooley DA, Livesay JJ, Ott DA, et al
. Sinus of Valsalva aneurysm or fistula: Management and outcome. Ann Thorac Surg 1999;68:1573-7.
Sinha SC, Sujatha V, Mahapatro AK. Percutaneous transcatheter closure of ruptured sinus of Valsalva aneurysm: Immediate result and long-term follow-up. Int J Angiol 2015;24:99-104.
Arora R, Trehan V, Rangasetty U, Mahesh C, Mukhopadhyay S, Thakur AK, et al
. Transcatheter closure of ruptured sinus of Valsalva aneurysm. J Interv Cardiol 2004;17:53-8.
Chandra S, Vijay SK, Dwivedi SK, Saran RK. Delineation of anatomy of the ruptured sinus of Valsalva with three-dimensional echocardiography: The advantage of the added dimension. Echocardiography 2012;29:E148-51.
Sarupria A, Kapoor PM, Makhija N, Kiran U. Trans-esophageal echocardiography: An indispensible guide for transcatheter device closure of ruptured sinus of Valsalva aneurysm. Ann Card Anaesth 2012;15:156-7. [Full text]
Zhang B, Sun Y, Wu J, Zhu JY, Cao R, Liu XL, et al
. Failed transcatheter closure of a giant ruptured sinus of Valsalva aneurysm. Chin Med J (Engl) 2015;128:1985-6.
Karlekar SM, Bhalghat P, Kerkar PG. Complete heart block following transcatheter closure of ruptured sinus of Valsalva aneurysm. J Invasive Cardiol 2012;24:E314-7.
Sakakibara S, Konno S. Congenital aneurysm of the sinus of Valsalva. Anatomy and classification. Am Heart J 1962;63:405-24.
Cho YH, Yong HS, Baek MJ, Na JO, Ryu YG, Kim HJ, et al
. Sinus of Valsalva aneurysm from left sinus: Value of angioscopic view of a 3-dimensional computed tomographic angiography. Circ Cardiovasc Imaging 2013;6:156-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]