Transcatheter closure of ruptured sinus of valsalva to left ventricle.

We report a rare case of ruptured right sinus of valsalva into the left ventricle (LV). Transthoracic echocardiography showed a marked turbulent flow from the right aortic sinus to the LV. We describe a novel technique of closure of this defect with duct occluder, involving the formation of an arterio-arterial loop, without resorting to the usual arteriovenous loop.

INTRODUCTION

Aneursyms of sinuses of valsalva are rare comprising 1% of all congenital heart disease.[1] They are thin-walled outpouchings of the sinus of valsalva and may be tubular or saccular in shape. The right sinus of valsalva is the most commonly involved and usually ruptures into right heart chambers. Uncommonly they rupture into left heart chambers (left atrium, left ventricle [LV]), pulmonary artery, interventricular septum, or the pericardial cavity.[1] We report a young boy who was diagnosed to have an aneurysm of the right sinus of valsalva with rupture into LV that was closed by duct occluder.

CASE REPORT

A 12-year-old boy presented with complaints of dyspnea (New York Heart Association II) over the previous 2 years. Transthoracic echocardiography (ECHO) showed a marked turbulent pan-diastolic flow from the right aortic sinus to the LV [Figure 1]. Transoesophageal ECHO confirmed the findings [Figure 2, Video 1]. The defect measured 5 mm at the aortic end. There was mild aortic regurgitation through the native aortic valve.

Figure 1

Transthoracic echocardiography — Apical five chamber view showing ruptured sinus of valsalva to left ventricle

Figure 2

Transesophageal echocardiography — Long axis view showing ruptured sinus of valsalva to left ventricle

We decided to close the ruptured sinus of valsalva (RSOV) using a duct occluder. The right femoral artery was cannulated with 6F sheath. Aortogram confirmed the RSOV from right coronary sinus to LV, defect measuring 5 mm at the aortic end, away from the right coronary ostium and below the sinotubular junction [Figure 3, Video 2]. The RSOV was crossed from the aorta into the LV using a 6F multipurpose and a 0.035" (300 cm exchange length) terumo glide wire. The glide wire was passed up into the ascending aorta and then into descending aorta. The glide wire was snared out from the left femoral artery using a 6F, 20 cm loop goose neck snare and exteriorized making an arterioarterial loop. A 7F, 110 cm sheath was tracked from left femoral artery over this wire through the LV and RSOV into ascending aorta. An 8/10 Lifetech PDA device (Lifetech Scientific Company Ltd., Shenzhen, China) was backloaded onto the 110 cm long sheath using a short 6F sheath. The position of the device was ascertained under fluoroscopy and transthoracic ECHO. Aortogram confirmed adequate position and complete closure of the defect. Post deployment angiogram revealed good result [Figure 4]. The patient remained hemodynamically stable throughout the procedure. Transthoracic ECHO was done after 6 months showed no residual shunt and aortic regurgitation was trivial.

Figure 3

Aortic root angiogram showing ruptured sinus of valsalva to left ventricle

Figure 4

Aortic root angiogram post device deployment

DISCUSSION

Most aneurysms are congenital in origin, but they may be seen after bacterial endocarditis, atherosclerosis or chesttrauma.[2] Aneurysms of sinus of valsalva are thought to result from the absence of normal elastic and muscular tissue, which leads to thinning of the wall of the aortic sinus.[2] Congenital sinus of valsalva aneurysms have been associated with other congenital defects such as ventricular septal defect (VSD), aortic regurgitation, and bicuspid aortic valve. In a study of 361 patients collected from Western and oriental literature by Chu et al., pathological rupture of sinus of valsalva most frequently involved the right sinus (76.8%), followed by the noncoronary (20.2%), and least commonly, the left sinus of valsalva (3%).[3] Küçükoglu et al. reviewed the literature and found only 26 cases of RSOV into the LV,[4] right sinus was involved in 22 cases. Rupture of these sinuses can manifest as sudden cardiac death, congestive cardiac failure or arrhythmias.[1] RSOV to LV must be differentiated from the aortico-LV tunnel. Aortico-LV tunnel arises above sino-tubular junction, and the sinus is normal.[5]

Transcatheter closure of a ruptured aneurysm of a sinus of Valsalva was first performed by Cullen et al. in 1994 using a Rashkind Umbrella device and retrograde arterial approach.[6] Jayaranganath et al. deployed the VSD occluder from the aortic end of a RSOV.[7] RSOV have been managed nonsurgically with various ductal and septal occluders.[89101112] Unlike the duct occlude, which needs to be deployed from the right ventricle side, the VSD occluder can also be deployed from the aortic end of RSOV. Arterio-arterial loop formation for the closure of a RSOV has not been previously described.

CONCLUSION

Ruptured aneurysms of sinuses of Valsalva can be managed nonsurgically. The technique described here, though not previously used, is both safe and quicker than antegrade trans-septal approach.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.