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Transcatheter Closure of Giant Ruptured Sinus of Valsalva Aneurysm

2013; Lippincott Williams & Wilkins; Volume: 128; Issue: 1 Linguagem: Inglês

10.1161/circulationaha.112.113365

1524-4539

Feng Chen, Song Hua Li, Yong Qin, Pan Li, Su Xuan Liu, Dong Jiang, Xian Zhao,

Vascular Malformations Diagnosis and Treatment

HomeCirculationVol. 128, No. 1Transcatheter Closure of Giant Ruptured Sinus of Valsalva Aneurysm Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBTranscatheter Closure of Giant Ruptured Sinus of Valsalva Aneurysm Feng Chen, MD, Song Hua Li, MD, Yong Wen Qin, MD, Pan Li, MD, Su Xuan Liu, MD, Jiang Dong, MD and Xian Xian Zhao, MD Feng ChenFeng Chen From the Departments of Cardiology (F.C., S.H.L., Y.W.Q., P.L., S.X.L., J.D., X.X.Z.) and Echocardiography (J.D.), Changhai Hospital, Second Military Medical University, Shanghai, China. , Song Hua LiSong Hua Li From the Departments of Cardiology (F.C., S.H.L., Y.W.Q., P.L., S.X.L., J.D., X.X.Z.) and Echocardiography (J.D.), Changhai Hospital, Second Military Medical University, Shanghai, China. , Yong Wen QinYong Wen Qin From the Departments of Cardiology (F.C., S.H.L., Y.W.Q., P.L., S.X.L., J.D., X.X.Z.) and Echocardiography (J.D.), Changhai Hospital, Second Military Medical University, Shanghai, China. , Pan LiPan Li From the Departments of Cardiology (F.C., S.H.L., Y.W.Q., P.L., S.X.L., J.D., X.X.Z.) and Echocardiography (J.D.), Changhai Hospital, Second Military Medical University, Shanghai, China. , Su Xuan LiuSu Xuan Liu From the Departments of Cardiology (F.C., S.H.L., Y.W.Q., P.L., S.X.L., J.D., X.X.Z.) and Echocardiography (J.D.), Changhai Hospital, Second Military Medical University, Shanghai, China. , Jiang DongJiang Dong From the Departments of Cardiology (F.C., S.H.L., Y.W.Q., P.L., S.X.L., J.D., X.X.Z.) and Echocardiography (J.D.), Changhai Hospital, Second Military Medical University, Shanghai, China. and Xian Xian ZhaoXian Xian Zhao From the Departments of Cardiology (F.C., S.H.L., Y.W.Q., P.L., S.X.L., J.D., X.X.Z.) and Echocardiography (J.D.), Changhai Hospital, Second Military Medical University, Shanghai, China. Originally published2 Jul 2013https://doi.org/10.1161/CIRCULATIONAHA.112.113365Circulation. 2013;128:e1–e3A 41-year-old woman presented with paroxysmal chest pain, dyspnea, and palpitations, and a continuous heart murmur was heard over the right upper and lower sternal borders. Transthoracic echocardiography revealed a giant ruptured sinus of Valsalva aneurysm (SOVA), which had dislodged and ruptured into the right atrium adjacent to the tricuspid valve. The diameter of the aortic end of the defect was 4 mm. Interestingly, this windsock SOVA swung into the right atrium and the right ventricle during different phases of the cardiac cycle (Figure 1 and Movie I in the online-only Data Supplement). Biatrial enlargement showed that the left atrial volume was 54 mL and the right atrial volume was 91 mL. We attempted to perform a transcatheter closure of this ruptured giant SOVA at the aortic end of the rupture site.Download figureDownload PowerPointFigure 1. A, Transthoracic echocardiogram obtained in the aortic short-axis view showing a giant windsock sinus of Valsalva aneurysm (SOVA), which had become dislodged and ruptured into the right atrium. It was adjacent to the tricuspid valve during systole. B, The SOVA swung into the right ventricle during diastole. AV indicates aortic valve; RA, right atrium; RV, right ventricle; and TV, tricuspid valve.An aortic angiogram confirmed the presence of the giant windsock SOVA (Figure 2 and Movie II in the online-only Data Supplement). A 6-mm modified double-disk ventricular occluder (Shanghai Shape Memory Alloy Ltd, China), similar to the Amplatzer occluder, was used in this procedure. The modified occluder (Figure 3) was made of 0.005-in nitinol wire mesh with fabric inside. The diameter of the left disk was 4 mm larger than the waist, and the right disk was 2 mm larger than the waist. The waist of the occluder was 3 mm thick. The modified double-disk ventricular occluder was approved by the State Food and Drug Administration of the People's Republic of China in 2003.1 During the postoperative evaluation, the right coronary ostium was located relatively high in relation to the SOVA. The ECG showed no changes in the S-T segment after the procedure. Transthoracic echocardiography was performed at that time, which revealed that the occluder was well fixed. There were no tricuspid or aortic regurgitation and no residual shunting. The aneurysm was shown to have been resolved completely; the left atrial volume was 47 mL, and the right atrial volume had decreased from 91 to 62 mL (Figure 4 and Movie III in the online-only Data Supplement). A repeat aortic angiogram confirmed that the giant SOVA had disappeared (Figure 5 and Movie IV in the online-only Data Supplement).Download figureDownload PowerPointFigure 2. The aortic angiogram confirmed a giant windsock sinus of Valsalva aneurysm.Download figureDownload PowerPointFigure 3. A modified double-disk ventricular occluder was applied in this procedure.Download figureDownload PowerPointFigure 4. Transthoracic echocardiogram image obtained in the aortic short-axis view showing that the occluder was well fixed.Download figureDownload PowerPointFigure 5. A repeat aortic angiogram confirmed that the giant sinus of Valsalva aneurysm had been completely resolved and that there was no procedure-related aortic regurgitation.SOVAs are relatively more common in adolescent and young adult Asian populations, with recorded incidences of 0.46% to 3.5% in Eastern countries compared with 0.14% to 0.23% in studies from Western areas.2 It is usually a congenital anomaly in which a dilatation of the aortic wall is located between the aortic valve and the sinotubular junction. In this present case, the aortic angiogram revealed that the SOVA originated from the right sinus of Valsalva and ruptured into the right atrium, creating a left-to-right shunt with profound hemodynamic effects. Patients with unruptured SOVAs may not manifest clinical symptoms for many years. When the rupture is sudden, the patient may present with chest pain and heart failure.Although surgical procedures are generally acknowledged as the gold standard of treatment for ruptured SOVAs, with recent advances in the nonsurgical closure of other left-to-right shunts, transcatheter closure has been suggested as an attractive alternative to surgery, with encouraging short-term and midterm outcomes.3 The present case was a technical challenge. First, the aneurysm measured 41×34 mm at the maximal echocardiographic diameters. To the best of our knowledge, this was the largest size recorded in patients with this rare form of SOVA undergoing transcatheter closure. Second, the transthoracic echocardiography revealed that the aneurysm was adjacent to the tricuspid valve. During the catheterization procedure, it was necessary to monitor for the occurrence of aortic or tricuspid regurgitation and residual shunting with color Doppler. Third, choosing a suitable occluder was paramount. To date, no specific equipment for such closures has been developed. The Amplazter duct occluder has been widely used recently, and a ventricular septal defect occluder has also been used in some patients.4 According to our experience, the ventricular septal defect occluder device was chosen on the basis of the anatomy of the defect, which was similar to an aneurysm-like ventricular septal defect. To avoid the influence of the right ventricular outflow tract as much as possible, we decided to occlude the defect at the aortic end and therefore selected a 6-mm ventricular septal defect occluder that was 2 mm larger than the aortic end of the defect. At the 1-year follow-up assessment, transthoracic echocardiography revealed that the occluder was well fixed and that there was no procedure-related aortic insufficiency (Figure 6).Download figureDownload PowerPointFigure 6. Successful occlusion of the ruptured aneurysm was confirmed in the left ventricular long-axis and aortic short-axis views by transthoracic echocardiogram.We report the incidental finding of a ruptured giant SOVA. Although the catheterization procedure was challenging, the procedure was successful, which suggests that transcatheter closure is a safe and effective approach. Such an intervention could become an attractive alternative treatment to surgery for appropriately selected patients with ruptured SOVAs.DisclosuresNone.FootnotesDrs Chen and S.H. Li contributed equally to this article.The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.112.113365/-/DC1.Correspondence to Xian Xian Zhao, MD, Department of Cardiology, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, China. E-mail [email protected]References1. Qin Y, Chen J, Zhao X, Liao D, Mu R, Wang S, Wu H, Guo H. Transcatheter closure of perimembranous ventricular septal defect using a modified double-disk occluder.Am J Cardiol. 2008; 101:1781–1786.CrossrefMedlineGoogle Scholar2. Chu SH, Hung CR, How SS, Chang H, Wang SS, Tsai CH, Liau CS, Tseng CD, Tseng YZ, Lee YT. Ruptured aneurysms of the sinus of Valsalva in Oriental patients.J Thorac Cardiovasc Surg. 1990; 99:288–298.CrossrefMedlineGoogle Scholar3. Kerkar PG, Lanjewar CP, Mishra N, Nyayadhish P, Mammen I. Transcatheter closure of ruptured sinus of Valsalva aneurysm using the Amplatzer duct occluder: immediate results and mid-term follow-up.Eur Heart J. 2010; 31:2881–2887.CrossrefMedlineGoogle Scholar4. Schaeffler R, Sarikouch S, Peuster M. Transcatheter closure of a ruptured sinus of Valsalva aneurysm (RSVA) after aortic valve replacement using the Amplatzer muscular VSD Occluder.Clin Res Cardiol. 2007; 96:904–906.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kuriakose E, Bhatla P and McElhinney D (2015) Comparison of Reported Outcomes With Percutaneous Versus Surgical Closure of Ruptured Sinus of Valsalva Aneurysm, The American Journal of Cardiology, 10.1016/j.amjcard.2014.11.013, 115:3, (392-398), Online publication date: 1-Feb-2015. Zhang B, Sun Y, Wu J, Zhu J, Cao R, Liu X and Yu B (2015) Failed Transcatheter Closure of a Giant Ruptured Sinus of Valsalva Aneurysm, Chinese Medical Journal, 10.4103/0366-6999.160624, 128:14, (1985-1986), Online publication date: 20-Jul-2015. Zhong L, Tong S, Zhang Q, Zhang Z, Yao Q, Li Y, Zhang W and Song Z (2014) Clinical efficacy and safety of transcatheter closure of ruptured sinus of valsalva aneurysm, Catheterization and Cardiovascular Interventions, 10.1002/ccd.25323, 84:7, (1184-1189), Online publication date: 1-Dec-2014. Fang Z, Huang Y, Tang L, Hu X, Shen X, Tang J and Zhou S (2014) Long-Term Outcomes of Transcatheter Closure of Ruptured Sinus Valsalva Aneurysms Using Patent Ductus Arteriosus Occluders, Circulation Journal, 10.1253/circj.CJ-14-0106, 78:9, (2197-2202), . Cheng T, Yang Y, Xie M, Wang X, Dong N, Su W, Lü Q, He L, Lu X, Wang J, Li L and Yuan L (2014) Echocardiographic diagnosis of sinus of Valsalva aneurysm: A 17-year (1995–2012) experience of 212 surgically treated patients from one single medical center in China, International Journal of Cardiology, 10.1016/j.ijcard.2014.02.003, 173:1, (33-39), Online publication date: 1-Apr-2014. Liu S, Xu X, Chen F, Zhao Z, Zhang Y, Wang C, Xiang J, Wu G, Chen X, Zhao X and Qin Y (2014) Angiographic features of ruptured sinus of Valsalva aneurysm: New classification, Journal of Cardiology, 10.1016/j.jjcc.2013.12.004, 64:2, (139-144), Online publication date: 1-Aug-2014. Liu S, Xu X, Zhao X, Chen F, Bai Y, Li W, Zhang Y, Wang C, Xiang J, Wu G, Chen X and Qin Y (2014) Percutaneous closure of ruptured sinus of Valsalva aneurysm: results from a multicentre experience, EuroIntervention, 10.4244/EIJV10I4A87, 10:4, (505-512), Online publication date: 1-Aug-2014. July 2, 2013Vol 128, Issue 1 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.112.113365PMID: 23817486 Originally publishedJuly 2, 2013 PDF download Advertisement SubjectsCatheter-Based Coronary and Valvular Interventions